Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances Nursing School Test Banks

Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

1. A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?
a. A 36-year-old who is prescribed long-term steroid therapy
b. A 55-year-old receiving hypertonic intravenous fluids
c. A 76-year-old who is cognitively impaired
d. An 83-year-old with congestive heart failure
ANS: C
Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

DIF: Understanding/Comprehension REF: 156 KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
a. Measure intake and output every 4 hours.
b. Apply oxygen by mask or nasal cannula.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowlers position.
ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowlers position will not address the clients problem.

DIF: Applying/Application REF: 156 KEY: Hydration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching?
a. I must drink a quart of water or other liquid each day.
b. I will weigh myself each morning before I eat or drink.
c. I will use a salt substitute when making and eating my meals.
d. I will not drink liquids after 6 PM so I wont have to get up at night.
ANS: B
One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

DIF: Analyzing/Analysis REF: 156 KEY: Hydration
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

4. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b. Daily weight increase from 55 kg to 57 kg
c. Heart rate decrease from 100 beats/min to 82 beats/min
d. Respiratory rate increase from 12 breaths/min to 15 breaths/min
ANS: A
ACE inhibitors will disrupt the reninangiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the clients blood pressure.

DIF: Applying/Application REF: 166
KEY: Hydration| angiotensin-converting enzyme (ACE) inhibitor
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

5. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
a. Client taking furosemide (Lasix)
b. Anxious client who has tachypnea
c. Client who is on fluid restrictions
d. Client who is constipated with abdominal pain
ANS: B
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.

DIF: Applying/Application REF: 153 KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 breaths/min to 22 breaths/min
b. Decreased skin turgor on the clients posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic light-headedness and dizziness
ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.

DIF: Applying/Application REF: 156 KEY: Hydration
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

7. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates the client correctly understood the teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole wheat crackers
d. Grilled chicken breast with glazed carrots
ANS: D
Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are often high in sodium.

DIF: Applying/Application REF: 157
KEY: Electrolyte imbalance MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

8. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
a. A 34-year-old on NPO status who is receiving intravenous D5W
b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)
ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

DIF: Applying/Application REF: 161
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

9. A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching?
a. Weigh yourself every morning and every night.
b. Check your radial pulse twice a day.
c. Read food labels to determine sodium content.
d. Bake or grill the meat rather than frying it.
ANS: C
Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.

DIF: Applying/Application REF: 160
KEY: Electrolyte imbalance MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

10. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography
ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the clients respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the clients respiratory status.

DIF: Analyzing/Analysis REF: 164
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

11. A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?
a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
b. Provide a heart healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d. Prepare the client for hemodialysis treatment.
ANS: C
A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the clients current potassium level.

DIF: Applying/Application REF: 166
KEY: Electrolyte imbalance| insulin
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

12. A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?
a. Client with pancreatitis who has continuous nasogastric suctioning
b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
d. Client with uncontrolled diabetes and a serum pH level of 7.33
ANS: A
A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.

DIF: Understanding/Comprehension REF: 164
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

13. A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
a. Assess the clients respiratory rate, rhythm, and depth.
b. Measure the clients pulse and blood pressure.
c. Document findings and monitor the client.
d. Call the health care provider.
ANS: A
In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The clients pulse and blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.

DIF: Applying/Application REF: 163
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

14. After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching?
a. Toasted English muffin with butter and blueberry jam, and tea with sugar
b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
ANS: C
Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.

DIF: Applying/Application REF: 163
KEY: Electrolyte imbalance MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

15. A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond?
a. Potatoes and avocados can be substituted for fruit.
b. If you cook the fruit, the amount of potassium will be lower.
c. Berries, cherries, apples, and peaches are low in potassium.
d. You are correct. Fruit is very high in potassium.
ANS: C
Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.

DIF: Applying/Application REF: 163
KEY: Electrolyte imbalance
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity

16. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin (Calcimar).
ANS: B
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

DIF: Applying/Application REF: 169
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

17. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 liter of fluids each shift.
d. Dangle the client on the bedside before ambulating.
ANS: D
An older adult with moderate dehydration may experience orthostatic hypotension. The client should dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the clients urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

DIF: Applying/Application REF: 157
KEY: Electrolyte imbalance| safety| mobility/immobility
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

MULTIPLE RESPONSE

1. A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skin
e. Skeletal muscle weakness
ANS: A, B, E
Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.

DIF: Remembering/Knowledge REF: 159 KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.)
a. A 36-year-old who is malnourished
b. A 42-year-old with uncontrolled diabetes
c. A 50-year-old with hyperparathyroidism
d. A 58-year-old with chronic renal failure
e. A 76-year-old who is prescribed antacids
ANS: A, B, E
Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxidebased or magnesium-based antacids. Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.

DIF: Remembering/Knowledge REF: 170
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L
e. Blood osmolality of 250 mOsm/L
ANS: B, E
Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the clients risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.

DIF: Applying/Application REF: 161 KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)
a. Electrocardiogram changes
b. Slow, shallow respirations
c. Orthostatic hypotension
d. Paralytic ileus
e. Skeletal muscle weakness
ANS: A, D, E
Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia.

DIF: Applying/Application REF: 152
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)
a. Hypokalemia Flaccid paralysis with respiratory depression
b. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
c. Hyponatremia Decreased level of consciousness
d. Hypercalcemia Positive Trousseaus and Chvosteks signs
e. Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension
ANS: A, C
Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is associated with hypophosphatemia or hypercalcemia. Positive Trousseaus and Chvosteks signs are associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated with hypermagnesemia.

DIF: Analyzing/Analysis REF: 164
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.)
a. Respiratory rate of 8 breaths/min
b. Absent deep tendon reflexes
c. Strong productive cough
d. Active bowel sounds
e. U waves present on the electrocardiogram (ECG)
ANS: C, D
A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not demonstrate that treatment is working.

DIF: Understanding/Comprehension REF: 165
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

7. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.)
a. Encourage oral fluid intake of at least 2 L/day.
b. Use a draw sheet to reposition the client in bed.
c. Strain all urine output and assess for urinary stones.
d. Provide nonslip footwear for the client to use when out of bed.
e. Rotate the client from side to side every 2 hours.
ANS: B, D
Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client wear nonslip footwear when out of bed to prevent fractures and falls. The other interventions would not provide safety for this client.

DIF: Applying/Application REF: 169
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

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