The physician orders a 2 gram sodium diet for a patient with hypertenstion. Which food should the nurse teach a patient to avoid?
A. american cheese
B. shredded wheat
One ounce of american cheese contains 406 mg of sodium and should be avoided on a 2 gram sodium diet
A patient receiving a tube feeding develops diarrhea. The nurse understands that the primary reason tube feedings cause diarrhea is b/c they are:
Hypertonic solutions have a greater concentration of solutes than does the blood. The high osmolarity of a hypertonic tube feedings exerts an osmotic force that pulls fluid into the stomach and intestine, resulting in intestinal cramping and diarrhea.
The nurse suspects that an older patient may have a problem with excess fluid volume when the patient's skin appears:
A. dry and scaly
B. taut and shiny
C. red and irritated
D. thin and inelastic
Taut and shiny
With excessive fluid volume, the increased hydrostatic pressure moves fluid from the intravascular compartment into the interstitial compartment (edema), the skin appears taut and shiny.
When a patient is under extreme stress, there is an increased production of antidiuretic hormone (ADH) and aldosterone. Considering the effect of these hormones in the body, the nurse should expect a decrease in the patients:
A. blood pressure
B. urinary output
C. body temperature
D. insensible fluid loss
Both hormones are involved with water reabsorption, which conserves fluid and results in a decreased urinary output.
The nurse is providing dietary teaching for a patient with the diagnosis of osteoporosis. The nurse should teach the paient that the best source of calcium is:
Cheese, a dietary product, is an excellent dietary source of calcium. One ounce of cheese contains approx. 150 mg to 406 mg of calcium depending on the type of cheese.
The nurse is monitoring a patient who is receiving IV fluid. The nurse identifies that the patient is experiencing a fluid overload when assessment reveals:
A. chills, fever, and generalized discomfort
B. blood in the tubing close to the insertion site
C. dyspnea, headache, and icnreased blood pressure
D. pallor, swelling, and discomfort at the insertion site
Dyspnea, headache, and increased blood pressure
Rationale: IV fluid flows directly into the circulatory system via a vein. Excess intravascular volume (hypervolemia) causes hypertension, pulmonary edema, and headache.
When caring for a patient with hypertension, the nurse should anticipate that the physician will first limit the patient's intake of:
In the stepped-care approach to the management of hypertension, sodium intake is restricted in step 1.
The nurse understands that excess fluid in the interstitial compartment results from increased:
A. oncotic pressure
B. diffusion pressure
C. hydrostatic pressure
D. intraventricular pressure
Hydrostatic pressure is the pressure exerted by a fluid within a compartment, such as blood within the vessels. Hydrostatic pressure moves fluid from an area of greater pressure to an area of lesser pressure. Hydrostatic pressure within vessels of the body moves fluid out of the intravascular compartment into the interstitial compartment. Interstitial fluid is extracellular fluid that surrounds cells.
The physician orders hydrochlorothiazide, a diuretic for a patient who is retaining fluid. The nurse should encourage the patient to ingest nutrients rich in:
Rationale: most diuretics affect the renal mechanisms for tubular secretion and reabsorption of electrolytes, particularly potassium. Potassiums therapeutic window is 3.5-5.0 meq/L
When the nurse cares for an older adult, which assessment best reflects fluid and electrolyte balance?
A. intake and output results
B. serum laboratory values
C. condition of the skin
D. presence of tenting
Serum laboratory values
Lab studies provide objective measurements of indicators of fluid, electrolyte, and acid-base balance.
A patient has a continuous bladder irrigation. What should the nurse do with the irrigant on the I & O sheet when calculating the fluid balance for this patient?
A. add it to the oral intake column
B. deduct it from the total urine output
C. subtract it from the intravenous flow sheet as output
D. document the intake hourly in the urine output column
Deduct it from the total urine output
When a continuous bladder irrigation is in use, drainage from the urinary bladder will consist of both urine and the instilled irrigant. To determine the patients urinary output, the amt of the irrigant instilled must be deducted form the total urinary output.
The patient is receiving a diuretic that contributes to the loss of potassium. THe nurse should teach the patient that the best source of potassium is:
A. baked potato
B. bran flakes
C. lean meat
D. table salt
A 1/2 pound baked potato contains approx 844 mg of potassium.
The physician orders a patients IV fluids to be discontinued. When discontinuing a patients IV infusion, it is essential that the nurse:
A. withdraw the catheter along the same angle of its insertion
B. use an alcohol swab to scrub the insertion site
C. flush the line with normal saline
D. don sterile gloves
Withdraw the catheter along the same angle of its insertion
Rationale: Removing the catheter by withdrawing it along the same path of its insertion minimizes injury to the vein and trauma around the surronding tissue. This action limits seepage of blood and promotes healing of the puncture wounds.
A patient is admitted to the hospital for a fever of unkown origin. The nursing assessment revels profuse diaphoresis, dry sticky mucous membranes, weakness, disorientation, and a decreasing level of consiousness. The nurse infers that the patient has: _______
With profuse diaphoresis, the water loss exceeds the sodium loss resulting in hypernatremia. Excess serum sodium precipitates changes in the musculoskeletal (weakness), neurlogic (disorientaiton and dereased LOC), and integumentary (dry, mucous membranes) systems
When a patient exhibits an increasing blood pressure and 2 pound weight gain over two days, the nurse should further assess the patient for:
A. a decrease in heart rate
B. an increase in skin turgor
C. an increase in pulse volume
D. a decrease in pulse pressure
An increase in pulse volume
Rationale: with an excess fluid volume the amount of circulating blood volume increases, resulting in full, bounding peripheral pulses
When assessing a patient, the nurse understands that an adpatation common to both excess fluid volume and deficient fluid volume is:
rationale: muscle weakness is a musculoskeletal adaptation to both increased fluid volume and decreased fluid volume b/c the fluid imbalances alter cellular and body metabolism
The physician orders an intravenous infusion containing potassium. Before administering this solution to the patient, it is essential that the nurse:
A. assess the skin turgor
B. obtain the blood pressure
C. measure the depth of edema
D. determine the presence of urinary output
Determine the presence of urinary output
Rationale: serum potassium has a narrow therapeutic window (3.5-5.0 meq/L). When kidney function is impaired, potassium can accumulate in the body and exceed the therapeutic level of 5.0 meq/L, which can cause cardiac dysrhythmias and arrest.
When patients are taking supplemental calcium, it is important that the nurse teach them to maintain their fluid intake at a minimum of 2500 ml a day to prevent the:
A. formation of kidney stones
B. occurence of muscle cramps
C. irritation of the bladder mucosa
D. mobilization of calcium from bone
formation of kidney stones
rationale: a high fluid intake increases the volume of urine produced. The resulting frequent urination of dilute urine prevents the formation of renal calculi, which may occur b/c of the increased precipitation of calcium salts associated with calcium supplementation
A patient receiving a diuretic is encouraged to increased the intake of potassium. The nurse evaluates that the patient understands the teaching when for dinner the patient selects:
A. baked salmon fillet
B. cooked chicken liver
C. cream of chicken soup
D. lettuce and tomato salad
Lettuce and tomato salad
rationale: lettuce and tomatoes are excellent sources of potassium. One 6 inch diameter head of iceberg lettuce contains 852 mg of potassium, and one 2 3/4 inch diameter tomato contains 255 mg of potassium.
The nurse is assessing a patients fluid status. What assessment indicates that the patient has a deficient fluid volume?
A. negative balance of intake and output
B. decreased body temperature
C. increased blood pressure
D. shortness of breath
negative balance of intake and output
Rationale: a patient has a negative balance of intake and output when the output exceeds the intake. This is a characteristic of a deficient fluid volume.
When the nurse evaluates the effectiveness of patient teaching, which food selections by a patient indicate understanding regarding an abundant source of calcium? Select all that apply
D. green beans
E. peanut butter
yogurt, green beans
yogurt is an excellent dietary source of calcium. 8 ounces of yogurt contain 415 mg of calcium. One cup of cooked fresh spinach contains 245 mg of calcium.
All central venous access devices infuse intravenous fluids into the:
C. superior vena cava.
Rationale:Although central venous access device catheters may be inserted into the jugular, subclavian, or brachial vein, the end of the catheter is threaded into the superior vena cava.
T or F: A goal of administering albumin intravenously is to increase oncotic pressure in the vascular space.
Rationale:Albumin is a large serum protein that draws fluid into the vascular space
T or F: The best overall measurement of total body fluid loss or gain is the measurement of intake and output.
Rationale:Intake and output only measures the fluid that enters and exits the vascular system. It will not measure the fluid contained interstitially or fluid that is in a third space.
Mrs. Katz has been admitted to the intermediate care unit with a diagnosis of acute gastrointestinal bleeding. Her blood pressure is 88/50 mm Hg, and her pulse is 120 bpm. The nurse would expect Mrs. Katz's intravenous therapy to be:
B. an isotonic fluid, such as normal saline.
Rationale:Although Mrs. Katz may need a blood transfusion, there is no data related to her hematocrit and hemoglobin levels. With a blood pressure of 88/50 mm Hg, she would need IV therapy to replace volume and correct her hypotension, and neither an intravenous lock nor hypotonic fluid would accomplish this goal.
Cammy Smith is brought to the emergency room following an attempted robbery. She is extremely distraught and is hyperventilating. If an arterial blood gas sample were to be obtained, the nurse would expect to find:
C. a rising pH and a falling PCO2.
Rationale:The patient would be developing respiratory alkalosis, which would be identified by a rise in pH and a decrease in the PCO2 due to the hyperventilation.
pH = 7.53 PCO2 = 26 mm Hg HCO3- = 22 mEq/L
pH = 7.40 PCO2 = 39 mm Hg HCO3- = 25 mEq/L
Normal ABG results
pH = 7.30 PCO2 = 70 mm Hg HCO3- = 30 mEq/L
Respiratory acidosis, partially compensated
pH = 7.48 PCO2 = 46 mm Hg HCO3- = 30 mEq/L
Metabolic alkalosis, partially compensated
Identify laboratory tests that monitor fluid, electrolytes, and acid-base balance.
Serum electrolytes measures sodium, potassium, chloride, and bicarbonate levels. Test often includes blood urea nitrogen (BUN), creatinine, and glucose.
Serum osmolality is a measure of the solute concentration of the blood.
Urine osmolality is the solute concentration of urine.
Hematocrit is a measure of the percent of RBCs in whole blood.
Specific gravity measures fluid status.
ABGs measure acid-base balance.
Under what conditions would a central venous access device be preferable to a peripheral device?
A central venous access device would be preferable to a peripheral device in these situations:
When highly irritating or hyperosmolar solutions are administered
When the client is severely fluid depleted and a peripheral line cannot be started
When central venous pressure monitoring is ordered
What are the preferred locations for peripheral IV lines?
The most distal veins in the hands and arms are the preferred locations for peripheral IV lines.