Fluid and Electrolyte Balance (6)

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor’s order?

Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr

Furosemide (Lasix) 20 mg PO now

Oxygen via face mask at 8 L/min

KCl 20 mEq PO two times per day

The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician?

Weight gain of 2 pounds since last week

Dry mucous membranes and skin tenting

Urine output 8 mL/hr

Blood pressure 98/58

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician?

Swollen ankles in patient with compensated heart failure

Positive Chvostek’s sign in patient with acute pancreatitis

Dry mucous membranes in patient taking a new diuretic

Constipation in patient who has advanced breast cancer

At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia?

Vomiting all day and not replacing any fluid

Tumor that secretes excessive antidiuretic hormone (ADH)

Tumor that secretes excessive aldosterone

Tumor that destroyed the posterior pituitary gland

The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration?

Development of ankle or sacral edema

Increased skin tenting and dry mouth

Postural hypotension and tachycardia

Decreased level of consciousness

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium?

Severe hemorrhage

Diabetes insipidus

Oliguric renal disease

Adrenal insufficiency

The patient’s laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now?

Raise bed side rails due to potential decreased level of consciousness and confusion.

Examine sacral area and patient’s heels for skin breakdown due to potential edema.

Establish seizure precautions due to potential muscle twitching, cramps, and seizures.

Institute fall precautions due to potential postural hypotension and weak leg muscles.

The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Select all that apply.)

The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.)

Test for skin tenting.

Measure rate and character of pulse.

Measure postural blood pressure and heart rate.

Check Trousseau’s sign.

Observe for flatness of neck veins when upright.

Observe for flatness of neck veins when supine.