24
42
,888
940
, 2. Tumor lysis syndrome 1. U-waves
3. Increased intake of phosphorus, including 2. Absent-P-waves
dietary intake or overuse of phosphate- 3. Inverted-T-waves
containing laxatives or enemas 4. Depressed-ST-segment
4. Hypoparathyroidism 5. Widened-QRS-complex
C. Assessment: (see Table 8.5) CHAPTER-8 Fluids-and-Electrolytes 101
D. Interventions
1. Interventions-entail-the-management-of-
hypocalcemia. 4. Potassium-chloride-intravenously-is-prescribed-for-a-
2. Administer-phosphate-binding-medications- client-with-heart-failure-experiencing-hypokalemia.-Which-
that-increase-fecal-excretion-of-phosphorus- actions-would-the-nurse-take-to-plan-for-preparation-and-
by-binding-phosphorus-from-food-in-the- administration-of-the-potassium?
gastrointestinal-tract. Select-all-that-apply.
3. Instruct-the-client-to-avoid-phosphate- 1. Obtain-an-intravenous-(IV)-infusion-pump.
containing-medications,-including-laxatives- 2. Monitor-urine-output-during-administration.
and-enemas. 3. Prepare-the-medication-for-bolus-administration.
4. Instruct-the-client-to-decrease-the-intake-of- 4. Monitor-the-IV-site-for-signs-of-in ltration-or-phlebitis.
food-that-is-high-in-phosphorus-(see-Box- 5. Ensure-that-the-medication-is-diluted-in-the-appropriate-
11.2). volume-of- uid.
5. Instruct-the-client-in-medication- 6. Ensure-that-the-bag-is-labeled-with-the-volume-of-potassium-
administration:-Take-phosphate-binding- in-the-solution.
medications,-emphasizing-that-they-should-
be-taken-with-meals-or-immediately-after- 5. The-nurse-is-assessing-a-client-with-a-lactose-intolerance-
meals. disorder-for-a-suspected-diagnosis-of-hypocalcemia.-
Which-clinical-manifestation-would-the-nurse-expect-to-
note-in-the-client?-1.-Twitching
2. Hypoactive-bowel-sounds
P-R-A-C-T-I-C-E-Q-U-E-S-T-I-O-N-S 3. Negative-Trousseau’s-sign
4. Hypoactive-deep-tendon-re exes
1. The-nurse-is-caring-for-a-client-with-heart-
failure.-On-assessment,-the-nurse-notes-that- 6. The-nurse-is-caring-for-a-client-with-Crohn’s-disease-who-
the-client-is-dyspneic,-and-crackles-are- has-a-calcium-level-of-8-mg/dL-(2-mmol/L).-Which-
audible-on-auscultation.-What-additional- patterns-would-the-nurse-watch-for-on-the-
manifestations-would-the-nurse-expect-to- electrocardiogram?-Select-all-that-apply.
note-in-this-client-if-excess- uid-volume-is- 1. Peaked-T-wave
present?-1.-Weight-loss-and-dry-skin 2. Widened-T-wave
2. Flat-neck-and-hand-veins-and-decreased- 3. Prominent-U-wave
urinary-output 4. Prolonged-QT-interval
3. An-increase-in-blood-pressure-and-increased- 5. Prolonged-ST-segment
respirations
4. Weakness-and-decreased-central-venous- 7. The-nurse-reviews-the-electrolyte-results-of-a-client-with-
pressure-(CVP) chronic-kidney-disease-and-notes-that-the-potassium-
level-is-5.7-mEq/L-(5.7-mmol/L).-Which-patterns-would-
2. The-nurse-reviews-a-client’s-record-and- the-nurse-watch-for-on-the-cardiac-monitor-as-a-result-of-
determines-that-the-client-is-at-risk-for- the-laboratory-value?-Select-all-that-apply.
developing-a-potassium-de cit-if-which-situation- 1. ST-depression
is-documented?-1.-Sustained-tissue-damage 2. Prominent-U-wave
2. Requires-nasogastric-suction 3. Tall-peaked-T-waves
3. Has-a-history-of-Addison’s-disease 4. Prolonged-ST-segment
4. Uric-acid-level-of-9.4-mg/dL-(557-mcmol/L) 5. Widened-QRS-complexes
3. The-nurse-reviews-a-client’s-electrolyte- 8. Which-client-is-at-risk-for-the-development-of-a-sodium-
laboratory-report-and-notes-that-the-potassium- level-at-130-mEq/L-(130-mmol/L)?-1.-The-client-who-is-
level-is-2.5-mEq/L-(2.5-mmol/L).-Which-patterns- taking-diuretics
would-the-nurse-watch-for-on-the- 2. The-client-with-hyperaldosteronism
electrocardiogram-(ECG)-as-a-result-of-the- 3. The-client-with-Cushing’s-syndrome
laboratory-value?-Select-all-that-apply.
, 4. The-client-who-is-taking-corticosteroids 3. Integumentary-output
4. The-gastrointestinal-tract
9. The-nurse-is-caring-for-a-client-with-heart-
failure-who-is-receiving-high-doses-of-a-diuretic.- 12. The-nurse-is-assigned-to-care-for-a-group-of-clients.-On-
On-assessment,-the-nurse-notes-that-the-client- review-of-the-clients’-medical-records,-the-nurse-
has- at-neck-veins,-generalized-muscle- determines-that-which-client-is-most-likely-at-risk-for-a-
weakness,-and-diminished-deep uid-volume-de cit?
102 UNIT-III Foundations-of-Care 1. A-client-with-an-ileostomy
2. A-client-with-heart-failure
3. A-client-on-long-term-corticosteroid-therapy
tendon-re exes.-The-nurse-suspects- 4. A-client-receiving-frequent-wound-irrigations
hyponatremia.-What-additional-sign-would- 13. The-nurse-caring-for-a-client-with-heart-failure-who-has-
the-nurse-expect-to-note-in-a-client-with- been-receiving-intravenous-(IV)-diuretics-suspects-that-
hyponatremia?-1.-Muscle-twitches the-client-is-experiencing-a- uid-volume-de cit.-Which-
2. Decreased-urinary-output assessment- nding-would-the-nurse-note-in-a-client-
3. Hyperactive-bowel-sounds with-this-condition?-1.-Weight-loss-and-poor-skin-turgor
4. Increased-speci c-gravity-of-the- 2. Lung-congestion-and-increased-heart-rate
urine 3. Decreased-hematocrit-and-increased-urine-output
4. Increased-respirations-and-increased-blood-pressure
10. The-nurse-reviews-a-client’s-laboratory-report-
and-notes-that-the-client’s-serum-phosphorus- 14. On-review-of-the-clients’-medical-records,-the-nurse-
(phosphate)-level-is-1.8-mg/dL-(0.58-mmol/L).- determines-that-which-client-is-at-risk-for- uid-volume-
Which-condition-most-likely-caused-this- excess?
serum-phosphorus-level? 1. The-client-taking-diuretics-who-has-tenting-of-the-skin
1. Malnutrition 2. The-client-with-an-ileostomy-from-a-recent-abdominal-
2. Renal-insuf ciency surgery
3. Hypoparathyroidism 3. The-client-who-requires-intermittent-gastrointestinal-
4. Tumor-lysis-syndrome suctioning
4. The-client-with-kidney-disease-that-developed-as-a-
11. The-nurse-is-reading-a-physician’s-progress- complication-of-diabetes-mellitus
notes-in-the-client’s-record-and-reads-that-the-
physician-has-documented-“insensible- uid- 15. Which-client-is-at-risk-for-the-development-of-a-potassium-
loss-of-approximately-800-mL-daily.”-The- level-of-5.5-mEq/L-(5.5-mmol/L)?-1.-The-client-with-colitis
nurse-plans-to-monitor-the-client,-knowing- 2. The-client-with-Cushing’s-syndrome
that-insensible- uid-loss-occurs-through-which- 3. The-client-who-has-been-overusing-laxatives
type-of-excretion?-1.-Urinary-output 4. The-client-who-has-sustained-a-traumatic-burn
2. Wound-drainage
ANSWERS Reference:-Lewis,-S.,-Harding,-M.,-Kwong,-J.,-Roberts,-D.,-Hagler,-
D.,-&-Reinisch,-C.-(2020).-Medical-surgical-nursing:-Assessment-
1. Answer:-3 and-management-of-clinical-problems.-(11th-ed.).-St.-Louis:-
Rationale:-A-fluid-volume-excess-is-also-known-as- Elsevier.-pp.-740-741.
overhydration-or-fluid-overload-and-occurs-when-fluid-intake-
or-fluid-retention-exceeds-the-fluid-needs-of-the-body.- 2. Answer:-2
Assessment-findings-associated-with-fluid-volume-excess- Rationale:-The-normal-serum-potassium-level-is-3.5-to-5.0-
include-cough,-dyspnea,-crackles,-tachypnea,-tachycardia,- mEq/L-(3.5-to-5.0-mmol/L).-A-potassium-deficit-is-known-as-
elevated-blood-pressure,-bounding-pulse,-elevated-CVP,-weight- hypokalemia.-Potassium-rich-gastrointestinal-fluids-are-lost-
gain,-edema,-neck-and-hand-vein-distention,-altered-level-of- through-gastrointestinal-suction,-placing-the-client-at-risk-for-
consciousness,-and-decreased-hematocrit.-Dry-skin,-flat-neck- hypokalemia.-The-client-with-tissue-damage-or-Addison’s-
and-hand-veins,-decreased-urinary-output,-and-decreased-CVP- disease-and-the-client-with-hyperuricemia-are-at-risk-for-
are-noted-in-fluid-volume-deficit.-Weakness-can-be-present-in- hyperkalemia.-The-normal-uric-acid-level-ranges-from-2.7-to-8.5-
either-fluid-volume-excess-or-deficit. mg/-dL-(160-to-501-mcmol/L).
Test-Taking-Strategy:-Focus-on-the-subject,-fluid-volume- Test-Taking-Strategy:-Note-the-subject,-causes-of-potassium-
excess.-Remember-that-when-there-is-more-than-one-part-to- deficit.-First-recall-the-normal-uric-acid-levels-and-the-causes-of-
an-option,-all-parts-need-to-be-correct-in-order-for-the-option- hyperkalemia-to-assist-in-eliminating-option-4.-For-the-
to-be-correct.-Think-about-the-pathophysiology-associated- remaining-options,-note-that-the-correct-option-is-the-only-one-
with-a-fluid-volume-excess-to-assist-in-directing-you-to-the- that-identifies-a-loss-of-body-fluid.
correct-option.-Also,-note-that-the-incorrect-options-are- Reference:-Ignatavicius,-D.,-Workman,-M.,-Rebar,-C.,-&-
comparable-or-alike-in-that-each-includes-manifestations-that- Heimgartner,-N.-(2021).-Medical-surgical-nursing:-Concepts-for-
reflect-a-decrease.
42
,888
940
, 2. Tumor lysis syndrome 1. U-waves
3. Increased intake of phosphorus, including 2. Absent-P-waves
dietary intake or overuse of phosphate- 3. Inverted-T-waves
containing laxatives or enemas 4. Depressed-ST-segment
4. Hypoparathyroidism 5. Widened-QRS-complex
C. Assessment: (see Table 8.5) CHAPTER-8 Fluids-and-Electrolytes 101
D. Interventions
1. Interventions-entail-the-management-of-
hypocalcemia. 4. Potassium-chloride-intravenously-is-prescribed-for-a-
2. Administer-phosphate-binding-medications- client-with-heart-failure-experiencing-hypokalemia.-Which-
that-increase-fecal-excretion-of-phosphorus- actions-would-the-nurse-take-to-plan-for-preparation-and-
by-binding-phosphorus-from-food-in-the- administration-of-the-potassium?
gastrointestinal-tract. Select-all-that-apply.
3. Instruct-the-client-to-avoid-phosphate- 1. Obtain-an-intravenous-(IV)-infusion-pump.
containing-medications,-including-laxatives- 2. Monitor-urine-output-during-administration.
and-enemas. 3. Prepare-the-medication-for-bolus-administration.
4. Instruct-the-client-to-decrease-the-intake-of- 4. Monitor-the-IV-site-for-signs-of-in ltration-or-phlebitis.
food-that-is-high-in-phosphorus-(see-Box- 5. Ensure-that-the-medication-is-diluted-in-the-appropriate-
11.2). volume-of- uid.
5. Instruct-the-client-in-medication- 6. Ensure-that-the-bag-is-labeled-with-the-volume-of-potassium-
administration:-Take-phosphate-binding- in-the-solution.
medications,-emphasizing-that-they-should-
be-taken-with-meals-or-immediately-after- 5. The-nurse-is-assessing-a-client-with-a-lactose-intolerance-
meals. disorder-for-a-suspected-diagnosis-of-hypocalcemia.-
Which-clinical-manifestation-would-the-nurse-expect-to-
note-in-the-client?-1.-Twitching
2. Hypoactive-bowel-sounds
P-R-A-C-T-I-C-E-Q-U-E-S-T-I-O-N-S 3. Negative-Trousseau’s-sign
4. Hypoactive-deep-tendon-re exes
1. The-nurse-is-caring-for-a-client-with-heart-
failure.-On-assessment,-the-nurse-notes-that- 6. The-nurse-is-caring-for-a-client-with-Crohn’s-disease-who-
the-client-is-dyspneic,-and-crackles-are- has-a-calcium-level-of-8-mg/dL-(2-mmol/L).-Which-
audible-on-auscultation.-What-additional- patterns-would-the-nurse-watch-for-on-the-
manifestations-would-the-nurse-expect-to- electrocardiogram?-Select-all-that-apply.
note-in-this-client-if-excess- uid-volume-is- 1. Peaked-T-wave
present?-1.-Weight-loss-and-dry-skin 2. Widened-T-wave
2. Flat-neck-and-hand-veins-and-decreased- 3. Prominent-U-wave
urinary-output 4. Prolonged-QT-interval
3. An-increase-in-blood-pressure-and-increased- 5. Prolonged-ST-segment
respirations
4. Weakness-and-decreased-central-venous- 7. The-nurse-reviews-the-electrolyte-results-of-a-client-with-
pressure-(CVP) chronic-kidney-disease-and-notes-that-the-potassium-
level-is-5.7-mEq/L-(5.7-mmol/L).-Which-patterns-would-
2. The-nurse-reviews-a-client’s-record-and- the-nurse-watch-for-on-the-cardiac-monitor-as-a-result-of-
determines-that-the-client-is-at-risk-for- the-laboratory-value?-Select-all-that-apply.
developing-a-potassium-de cit-if-which-situation- 1. ST-depression
is-documented?-1.-Sustained-tissue-damage 2. Prominent-U-wave
2. Requires-nasogastric-suction 3. Tall-peaked-T-waves
3. Has-a-history-of-Addison’s-disease 4. Prolonged-ST-segment
4. Uric-acid-level-of-9.4-mg/dL-(557-mcmol/L) 5. Widened-QRS-complexes
3. The-nurse-reviews-a-client’s-electrolyte- 8. Which-client-is-at-risk-for-the-development-of-a-sodium-
laboratory-report-and-notes-that-the-potassium- level-at-130-mEq/L-(130-mmol/L)?-1.-The-client-who-is-
level-is-2.5-mEq/L-(2.5-mmol/L).-Which-patterns- taking-diuretics
would-the-nurse-watch-for-on-the- 2. The-client-with-hyperaldosteronism
electrocardiogram-(ECG)-as-a-result-of-the- 3. The-client-with-Cushing’s-syndrome
laboratory-value?-Select-all-that-apply.
, 4. The-client-who-is-taking-corticosteroids 3. Integumentary-output
4. The-gastrointestinal-tract
9. The-nurse-is-caring-for-a-client-with-heart-
failure-who-is-receiving-high-doses-of-a-diuretic.- 12. The-nurse-is-assigned-to-care-for-a-group-of-clients.-On-
On-assessment,-the-nurse-notes-that-the-client- review-of-the-clients’-medical-records,-the-nurse-
has- at-neck-veins,-generalized-muscle- determines-that-which-client-is-most-likely-at-risk-for-a-
weakness,-and-diminished-deep uid-volume-de cit?
102 UNIT-III Foundations-of-Care 1. A-client-with-an-ileostomy
2. A-client-with-heart-failure
3. A-client-on-long-term-corticosteroid-therapy
tendon-re exes.-The-nurse-suspects- 4. A-client-receiving-frequent-wound-irrigations
hyponatremia.-What-additional-sign-would- 13. The-nurse-caring-for-a-client-with-heart-failure-who-has-
the-nurse-expect-to-note-in-a-client-with- been-receiving-intravenous-(IV)-diuretics-suspects-that-
hyponatremia?-1.-Muscle-twitches the-client-is-experiencing-a- uid-volume-de cit.-Which-
2. Decreased-urinary-output assessment- nding-would-the-nurse-note-in-a-client-
3. Hyperactive-bowel-sounds with-this-condition?-1.-Weight-loss-and-poor-skin-turgor
4. Increased-speci c-gravity-of-the- 2. Lung-congestion-and-increased-heart-rate
urine 3. Decreased-hematocrit-and-increased-urine-output
4. Increased-respirations-and-increased-blood-pressure
10. The-nurse-reviews-a-client’s-laboratory-report-
and-notes-that-the-client’s-serum-phosphorus- 14. On-review-of-the-clients’-medical-records,-the-nurse-
(phosphate)-level-is-1.8-mg/dL-(0.58-mmol/L).- determines-that-which-client-is-at-risk-for- uid-volume-
Which-condition-most-likely-caused-this- excess?
serum-phosphorus-level? 1. The-client-taking-diuretics-who-has-tenting-of-the-skin
1. Malnutrition 2. The-client-with-an-ileostomy-from-a-recent-abdominal-
2. Renal-insuf ciency surgery
3. Hypoparathyroidism 3. The-client-who-requires-intermittent-gastrointestinal-
4. Tumor-lysis-syndrome suctioning
4. The-client-with-kidney-disease-that-developed-as-a-
11. The-nurse-is-reading-a-physician’s-progress- complication-of-diabetes-mellitus
notes-in-the-client’s-record-and-reads-that-the-
physician-has-documented-“insensible- uid- 15. Which-client-is-at-risk-for-the-development-of-a-potassium-
loss-of-approximately-800-mL-daily.”-The- level-of-5.5-mEq/L-(5.5-mmol/L)?-1.-The-client-with-colitis
nurse-plans-to-monitor-the-client,-knowing- 2. The-client-with-Cushing’s-syndrome
that-insensible- uid-loss-occurs-through-which- 3. The-client-who-has-been-overusing-laxatives
type-of-excretion?-1.-Urinary-output 4. The-client-who-has-sustained-a-traumatic-burn
2. Wound-drainage
ANSWERS Reference:-Lewis,-S.,-Harding,-M.,-Kwong,-J.,-Roberts,-D.,-Hagler,-
D.,-&-Reinisch,-C.-(2020).-Medical-surgical-nursing:-Assessment-
1. Answer:-3 and-management-of-clinical-problems.-(11th-ed.).-St.-Louis:-
Rationale:-A-fluid-volume-excess-is-also-known-as- Elsevier.-pp.-740-741.
overhydration-or-fluid-overload-and-occurs-when-fluid-intake-
or-fluid-retention-exceeds-the-fluid-needs-of-the-body.- 2. Answer:-2
Assessment-findings-associated-with-fluid-volume-excess- Rationale:-The-normal-serum-potassium-level-is-3.5-to-5.0-
include-cough,-dyspnea,-crackles,-tachypnea,-tachycardia,- mEq/L-(3.5-to-5.0-mmol/L).-A-potassium-deficit-is-known-as-
elevated-blood-pressure,-bounding-pulse,-elevated-CVP,-weight- hypokalemia.-Potassium-rich-gastrointestinal-fluids-are-lost-
gain,-edema,-neck-and-hand-vein-distention,-altered-level-of- through-gastrointestinal-suction,-placing-the-client-at-risk-for-
consciousness,-and-decreased-hematocrit.-Dry-skin,-flat-neck- hypokalemia.-The-client-with-tissue-damage-or-Addison’s-
and-hand-veins,-decreased-urinary-output,-and-decreased-CVP- disease-and-the-client-with-hyperuricemia-are-at-risk-for-
are-noted-in-fluid-volume-deficit.-Weakness-can-be-present-in- hyperkalemia.-The-normal-uric-acid-level-ranges-from-2.7-to-8.5-
either-fluid-volume-excess-or-deficit. mg/-dL-(160-to-501-mcmol/L).
Test-Taking-Strategy:-Focus-on-the-subject,-fluid-volume- Test-Taking-Strategy:-Note-the-subject,-causes-of-potassium-
excess.-Remember-that-when-there-is-more-than-one-part-to- deficit.-First-recall-the-normal-uric-acid-levels-and-the-causes-of-
an-option,-all-parts-need-to-be-correct-in-order-for-the-option- hyperkalemia-to-assist-in-eliminating-option-4.-For-the-
to-be-correct.-Think-about-the-pathophysiology-associated- remaining-options,-note-that-the-correct-option-is-the-only-one-
with-a-fluid-volume-excess-to-assist-in-directing-you-to-the- that-identifies-a-loss-of-body-fluid.
correct-option.-Also,-note-that-the-incorrect-options-are- Reference:-Ignatavicius,-D.,-Workman,-M.,-Rebar,-C.,-&-
comparable-or-alike-in-that-each-includes-manifestations-that- Heimgartner,-N.-(2021).-Medical-surgical-nursing:-Concepts-for-
reflect-a-decrease.
