A nurse is reading a Md's progress report and reads that the MD has documented "insensible fluid loss of approx. 800 ml daily." The nurse understands that this type of fluid loss can occur through? Show *hint- ans= press H 1. the GI tract ans 4 The nurse is assigned to care for a group of clients. On review of the clients' med. records, the nurse determines that which client is at risk for fluid volume deficit? *hint 1. clt with a colostomy ans 1 fluid vol deficits are: vomiting, diarrehea, increased respiration or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of ileostomy or colostomy A nurse is caring for a clt who has been taking diurectics on a long-term basis. The nurse suspects a fluid volume deficit. Which assessment finding would the nurse note in a clt with this condition? *hint 1. rales ans 4 increased respirations & HR, decreaed CVP, wgt loss, poor skin turgor, dry mucous membranes, decreased urine, The nurse is assigned to care for a group of clients. On review of the clients' med. records, the nurse determines that which client is at risk for fluid volume excess? *hint 1. clt with renal failure ans 1 excess includes: decreased kidney function, CHF, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities & excessive ingestion of sodium The nurse is caring for a clt with CHF.On assessment the nurse notes that the clt is dyspneic and that rales are audible on auscultation. The nurse suspects fluid volume excess. What additional signs would the nurse expect to note in this clt if fluid volume excess is present? *hint 1. a decreased central venous pressure (CVP) ans 3 cough, dyspnea, rales, tachypnea, tachycardia, an elevated BP & a bounding pulse, wg gain, edema, A nurse is preparing to care for a clt with a potassium deficit. The nurse reviews the clt's record and determines that the clt is at risk for developing the potassium deficit because the clt? *hint 1.requires nasogastric suction A nurse reviews a clt's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogrom as a result of the laboratory value? *hint 1. elevated T waves ans 4 EKG changes include inverted T waves. ST segment depression and prominent U waves A nurse prepares to admin. potassium chloride IV as prescribed to a clt with hypokalemia. Which of the following would not be a part of the nurse's plan regarding the preparation and and admin. of the potassium? *hint 1. prepare the med. for bolus administration A nurse instructs a clt at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is? *hint 1. spinach ans 4 has 159 mg of K, spinach has 470 mgs, carrot 341 mgs, avocado 1097 mg A nurse caring for a group of clients reviews the electrolyte lab results and notes a potassium level of 5.5 mEq/L on one client's lab. reports. The nurse understands that which client at most risk for the development of a potassium value at this level? *hint 1. the clt who has sustained a traumatic burn A nurse reviews the electrolyte results of an assigned clt and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the EKG as a result of the lab values? *hint 1. Tall peaked T waves A nurse caring for a group of clts reviews the electrolyte lab results and notes a sodium level of 130 mEq/L on one clt's lab reports. The nurse understands that which clt is at most risk for the development of a sodium value at this level? *hint 1. the clt who is taking diuretics A nurse is caring for a clt with acute congestive heart failure who is receiving high doses of a diuretic. On assessment the nurse notes that the clt has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? *hint 1. dry skin A nurse is caring for a clt with a nasogastric tube. NG tube irrigations are prescribed to be performed once every shift. The clt's serum electrolyte results indicate a potassium level of 4.5 mEq/L. Based on these lab findings the nurse selects which solution to use for the Ng Tube irrigation? *hint 1. tap water A nurse is reviewing lab results and notes that a clt's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the MD and the MD prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the clt to avoid? *hint 1. low-fat yogurt A nurse is reviewing a clt's lab reports and notes that the serum calcium level is 4.0 mg/dl. The nurse understands that which condition is most likely caused this serum calcium level? *hint 1.prolonged bed rest A nurse is assessing a clt with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations are not associated this diagnosis? *hint 1. Hypoactive bowel sounds A nurse caring for a clt with hypocalcemia would expect to note which of the following changes on the electrocardiogram? *hint 1. Prominent U wave A nurse caring for a clt with severe malnutrition reviews the lab results and notes a magnesium level of 1.0 mg/dl. Which EKG change would the nurse expect to note based on the magnesium level? *hint 1. Prominent U wave A nurse reviews the serum phosphorus level and notes that the clt's level is 2.0 mg/dl. Which condition most likely caused this serum phosphorus level? *hint 1. alcoholism A nurse plans care for a clt with chronic obstructive pulmonary disease, knowing that the clt is most likely to experience what type of acid-base imbalance? *hint 1.respiratory acidosis A nurse reviews the blood gas results of a cl with Guillain-Barre syndrome. The nurse analyzes the results and determines that the clt is experiencing respiratory acidosis. Which of the following validates the nurse's findings? *hint 1. pH 7.50, Pco2=52 mm Hg A nurse is caring for a clt who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the clt is experiencing respiratory alkalosis. Which lab value would most likely be noted in this condition? *hint 1. sodium level of 145 mEq/L A nurse reviews the arterial blood gas results of a clt and notes the following: pH 7.45, Pco2 of 30 mm Hg, and bicarbonate concentration of 22 mEq/L. The nurse analyzes these results as indicating? *hint 1. metabolic acidosis, compensated A clt is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. B4 the blood is drawn, an Allen's test is performed to determine the adequacy of the? *hint 1. popliteal circulation A nurse is caring for a clt with a NG tube that is attached to low suction. The nurse monitors the clt, knowing that the clt is at risk for which acid-base disorder? *hint 1. respiratory acidosis a nurse caring for a clt with an ileostomy understands that the clt is at most risk for developing which acid-base disorder? *hint 1. respiratory acidosis A nurse is caring for a clt with diabetic ketoacidosis and documents that the clt is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe? *hint 1. respirations that are abnormally deep, regular and increased in rate A nurse understands that the excessive use of antacids containing bicarbonate can result in which acid-base disturbance? *hint 1. respiratory acidosis A nurse is caring for a client with renal failure Bl. gas results indicate a pH of 7.30, a Pco2 of 32 mm Hg, and a bicarbonate concentration of 20 mEq/L. The nurse determined that the clt is experiencing metabolic acidosis. Which of the following lab values would the nurse expect to note? *hint 1.sodium level of 145 mEq/L What manifestation of extracellular fluid volume excess does the nurse anticipate finding?What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit.
What are the clinical manifestations of fluid volume excess?The signs of hypervolemia include: swelling, also called edema, most often in the feet, ankles, wrists, and face. discomfort in the body, causing cramping, headache, and stomach bloating. high blood pressure caused by excess fluid in the bloodstream.
What causes fluid deficit?The body may lose too much fluid due to diarrhea, vomiting, severe blood loss, or high fever. Lack of a hormone called antidiuretic hormone (ADH) can cause the kidneys to get rid of too much fluid. This results in extreme thirst and dehydration.
What additional signs would the nurse expect to note in this client if hyponatremia were present?The signs and symptoms associated with hyponatremia include confusion, vomiting, seizures, muscle weakness, nausea, headaches, loss of energy, fatigue, and restlessness and irritability.
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Which finding would the nurse expect during assessment of a client with fluid volume deficit?
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