Prepare: Nursing Care of Altered Fluid Balance

• A client with heart failure is admitted due to shortness of breath in the emergency room. Upon assessment, the nurse found the following:

Based on the data above, what are the appropriate nursing diagnoses for this client? Select all that apply.

Medication Effects on Fluid Volume

• What medication will help to excrete the excess fluid volume in the body?

Diagnostic Testing and Fluid Imbalances

• Which diagnostic tests will help to identify any altered fluid balance in the body? Select all that apply.

Self-Check: Diagnostic Testing of Fluid Balance

• What diagnostic tests will help to determine if the client’s fluid imbalance is worsening or improving? Select all that apply.

Self-Check: Fluid Balance and Assessment

• The client with fluid volume deficit has been receiving 0.9% sodium chloride intravenous (IV) infusion at 50 ml/hr for the past 4 hours. Which assessment finding indicates that the client is developing fluid volume overload?

Self-Check: Nursing Diagnosis and Fluid Balance

• A client is admitted to the emergency room with shortness of breath. Assessment findings include:

Based on the case scenario above, what is your priority nursing diagnosis?

Self-Check: Priorities – Fluid Balance Excess

• In which order should the nurse complete these actions after admitting a client experiencing shortness of breath?

Self-Check: Risk for Injury – Fluid Balance

• Lets take a look back to our client admitted to the emergency room due to shortness of breath. In the findings below, identify and click on the data that can contribute to a nursing diagnosis “Risk for Injury”.

Reflect: Nursing Care of Altered Fluid Balance

Fluid Balance Outcomes

• A client with heart failure is admitted due to shortness of breath in the emergency room and has a fluid build-up in the bilateral lower lungs. Furosemide 80mg IV was administered and oxygen therapy was started. The nurse should notify the healthcare provider for which assessment finding?

Fluid Balance Evaluation

• The client received furosemide 20 mg IVP for one dose to help with fluid volume overload. What are the appropriate nursing interventions when administering this medication? Select all that apply.

Fluid Balance and Head Injury

• The nurse anticipates administering which intravenous fluids (IV) to a client with traumatic head injury? Select all that apply.

Fluid Balance and Disease Management

• The nurse identifies that clients with which clinical conditions require hypotonic IV fluids? Select all that apply.

Labs and Fluid Balance

• Which assessment findings indicate a client is experiencing altered fluid balance? Select all that apply.

Gastrointestinal Bleeding and Fluid Balance

• The nurse anticipates which assessment findings for a client with fluid volume deficit related to lower gastrointestinal bleeding? Select all that apply.

Fluid Balance and Electrolytes

• Which nursing interventions are appropriate for a client who has dilutional hyponatremia secondary to heart failure? Select all that apply.

Medications and Fluid Balance

• A client with peritonitis is taking multiple medications. The client has a history of COPD, heart failure and hypertension. The nurse anticipates the client may have altered fluid balance due to which medications prescribed for these conditions? Select all that apply.

Fluid Volume Deficit

Prepare: Nursing Care - Fluid Volume Deficit

Diagnostic Tests - Fluid Volume Deficit

• The client is transferred from assisted living facility to emergency department due to dehydration secondary to malnutrition. Based on the history of present illness, the client has not been eating for the past 4 days and had been refusing any oral fluids.
• The client is currently receiving 0.9% NaCl IV infusion at 50 ml/hour. Six hours ago the client was started on total parenteral nutrition (TPN) at 50 mL/hr. Which current assessment finding should be reported to the healthcare provider?

Fluid Volume Deficit and Central Venous Access Device

• The client is transferred from assisted living facility to emergency department due to dehydration secondary to malnutrition. Based on the history of present illness, the client has not been eating for the past 4 days and had been refusing any oral fluids.
• The client is currently receiving 0.9% NaCl IV infusion at 50 ml/hour via a newly inserted peripherally inserted central catheter (PICC) line in the right cephalic vein. The vital signs are HR=115, RR=24, BP=150/76,Temp=99 degrees Fahrenheit and oxygen saturation 90%. What should the nurse do first?

Assessment: Fluid Volume Deficit

• The client is transferred from assisted living facility to emergency department due to dehydration secondary to malnutrition. Based on the history of present illness, the client has not been eating for the past 4 days and had been refusing any oral fluids

The client is currently receiving 0.9% NaCl and TPN IV through a PICC line. Which assessment findings place the client at high risk for fluid volume deficit? Select all that apply.

Self-Check: Nursing Care - Fluid Volume Deficit

• A client is admitted in the emergency department due to episodes of defecating stools with some streaks of blood. The wife verbalized that this has been happening for the past 3 days. Upon assessment, the client is pale, lips are dry, and he is confused. In addition, the client has a past medical history of diabetes mellitus type II and had escherichia coli infection in his urine last week. The vital signs are temperature 97 degrees Fahrenheit, RR 24 breaths/minute, HR 105 beats per minute, BP 90/50 mm Hg and 88% oxygen saturation in room air. Based on the assessment data, what are the appropriate nursing interventions? Select all that apply.

Self-Check: Assessment - Fluid Volume Deficit

• A client is admitted in the emergency department due to episodes of defecating stools with some streaks of blood. The wife verbalized that this has been happening for the past 3 days. Which assessment findings would support that the client is experiencing fluid volume deficit? Select all that apply.

Self-Check: Laboratory Values

Assessment - Fluid Volume Deficit

• A client is admitted in the emergency department due to episodes of defecating stools with some streaks of blood. The wife verbalized that this has been happening for the past 3 days. Upon assessment, the client seems pale, lips are dry and confused. Select the client’s laboratory results below that need immediate intervention.

Self-Check: Interprofessional Care Management - Fluid Volume Deficit

• A client is admitted to the emergency department due to episodes of defecating stools with some streaks of blood. The client’s wife verbalized that this has been happening for the past 3 days. Upon assessment, the client seems pale, lips are dry, and the client is confused

Based on the laboratory results above, what are the appropriate nursing interventions? Select all that apply.

Self-Check: Interprofessional Care Management - Gastrointestinal System

• The client who has been admitted due to episodes of defecating stools with some streaks of blood suddenly started vomiting. The ER nurse inserted the nasogastric tube for decompression and documented an output of 110 ml. Based on your assessment, the output now is at 200 ml.

Reflect: Nursing Care - Fluid Volume Deficit

Interprofessional Care Management – Gastrointestinal System

• The client is transferred from an assisted living facility to the emergency department due to dehydration secondary to malnutrition. Based on the history of present illness, the client has not been eating for the past 4 days and had been refusing any oral fluids. Total parenteral nutrition (TPN) is administered and has been infusing for the past 24 hours. Current blood results show:

What should the nurse do first?

Interprofessional Care Management – Hematology System

• A client is admitted to the emergency department due to episodes of defecating stools with some streaks of blood. The wife verbalized that this has been happening for the past 3 days. Upon assessment, the client seems pale, lips are dry and confused. The vital signs are T 97°F (36.1°C), RR 24 breaths/minute, HR 105 beats/minute, BP 90/50 mm Hg and 88% oxygen saturation on room air. Based on the assessment data, which action should the nurse take next?

Interprofessional Care Management – Safety

• A client is admitted to the emergency department due to episodes of defecating stools with some streaks of blood. The wife verbalized that this has been happening for the past 3 days with watery stools in between. Upon assessment, the client seems pale, lips are dry and confused. The vital signs are temp 97 degrees Fahrenheit, RR 24 breaths/ minute, HR 105 beats per minute, BP 90/50 mm Hg and 92% oxygen saturation on a 2 LPM nasal cannula. Based on the assessment data, what should the nurse do?

Assessment - Fluid Volume Deficit

• A client is admitted to the emergency department due to episodes of defecating stools with some streaks of blood. The wife verbalized that this has been happening for the past 3 days.

Based on the data, the priority nursing diagnosis is "fluid volume deficit related to episodes of defecating stools with some streaks of blood for the past 3 days." Select the assessment data above which data supports this.

Assessment – Neurological System

• The client has been receiving 0.45% NaCl IV infusion at 50 ml/hr. What assessment finding is the priority?

Prioritization and Delegation - Fluid Volume Deficit

• The registered nurse is delegating client assignments to unlicensed assistive personnel. Which client’s care can safely be delegated to the unlicensed assistive personnel (UAP)?

Assessment - Fluid Volume Deficit

• Which clinical conditions can cause fluid volume deficit? Select all that apply.

Interprofessional Care Management – Fluid Volume Deficit

• A client is admitted in the emergency department due to episodes of defecating stools with some streaks of blood. The wife verbalized that this has been happening for the past 3 days. Upon assessment, the client seems pale, lips are dry and confused. The client’s laboratory results are:

Based on the client’s laboratory values, the healthcare provider ordered blood transfusion. Prior to administering blood to the client, what should the nurse do first? (Select all that apply.)

Fluid Volume Excess

Prepare: Nursing Care of Fluid Volume Excess

Diagnostic Tests: Fluid Volume Excess

• The client is transferred from assisted living facility to emergency department due to shortness of breath secondary to exacerbation of heart failure. Based on the history of present illness, the client had episodes of respiratory distress for the past 2 days.

The client is currently received furosemide 40 mg IVP for one dose and oxygen therapy to help with her respiratory distress. What assessment finding needs immediate attention?

Urine Osmolality and Specific Gravity

• The client is transferred from assisted living facility to emergency department due to shortness of breath secondary to exacerbation of heart failure. Based on the history of present illness, the client had episodes of respiratory distress for the past 2 days. Upon admission of the client, urine sample was collected for urinalysis and random urine osmolality and urine specific gravity. The urine that was collected was 15 ml. This was the client’s output for the past 6 hours. Since the client has fluid volume overload related to the exacerbation of heart failure, what is the assessment finding that best supports a high urine osmolality and high urine specific gravity?

Fluid Volume Excess Predispositions

• Review the following data and select the assessment data that predisposes the client to develop fluid volume excess secondary to heart and respiratory failure.

Self-Check: Interprofessional Care Management

• A client is admitted in the emergency department due to episodes of shortness of breath and inability to walk due to edema in his lower extremities. The wife verbalized that this has been happening for 2 weeks. Upon assessment, the client is pale, diaphoretic and confused. He has diabetes mellitus type I, chronic bronchitis and was admitted in the hospital last month due to pneumonia. The vital signs are temp 99 degrees Fahrenheit, RR 27 breaths/minute, HR 105 beats per minute, BP 150/80 mm Hg and 88% oxygen saturation in room air. Based on the assessment data, what are the anticipated nursing actions? (Select all that apply).

Self-Check: Diagnostic Testing

• A client is admitted in the emergency department due to episodes of shortness of breath and inability to walk due to edema in his lower extremities. Their spouse verbalized that this has been happening for the last 2 weeks. Upon assessment, the client is pale, diaphoretic and confused. They have diabetes mellitus type I, chronic bronchitis, and were admitted to the hospital last month due to pneumonia. The vital signs are T 99 degrees Fahrenheit, RR 27 breaths/ minute, HR 105 beats per minute, BP 150/80 mm Hg and 88% oxygen saturation on room air. Select the laboratory values that need immediate action below.

Self-Check: Interprofessional Care Management - Fluid Volume Excess

• A client is admitted to the emergency department due to episodes of shortness of breath and inability to walk due to edema in his lower extremities. The client’s wife verbalized that this has been happening for 2 weeks. Upon assessment, the client is pale, diaphoretic and confused. He has diabetes mellitus type I, chronic bronchitis, and was admitted to the hospital last month due to pneumonia. The vital signs are temp 99 degrees Fahrenheit, RR 27 breaths/minute, HR 105 beats per minute, BP 150/80 mm Hg and 88% oxygen saturation in room air. PICTURE Based on the data above, what are the anticipated healthcare provider orders? Select all that apply.

Self-Check: Administering Medication

• The client with liver cirrhosis went to emergency department due to shortness of breath and difficulty of walking. The healthcare provider ordered albumin IV infusion 12.5 grams in 50 ml. How many ml/hour would it be to administer this medication within 30 minutes?

Self-Check: Interprofessional Care Management - Gastrointestinal System

• The client is admitted due to shortness of breath secondary to liver cirrhosis. Upon assessment, the client’s abdominal girth has increased for the past 2 days. The healthcare provider ordered albumin IV infusion for one dose to treat the ascites. After albumin, the healthcare provider ordered furosemide 20 mg IVP for one dose. Drag the words from the choices below to fill in each blank found in the following sentences:

Reflect: Nursing Care of Fluid Volume Excess

Interprofessional Care Management – Fluid Volume Excess

• A client is admitted in the emergency department due to episodes of shortness of breath and inability to walk due to edema in his lower extremities. The wife verbalized that this has been happening for the 2 weeks. Upon assessment, the client is pale, diaphoretic and confused. He has diabetes mellitus type I, chronic bronchitis and was admitted in the hospital last month due to pneumonia. The vital signs are temp 99 degrees Fahrenheit, RR 27 breaths/ minute, HR 105 beats per minute, BP 150/80 mm Hg and 88% oxygen saturation in room air. The client is currently receiving 3% NaCl IV fluid in a 50-ml bag at 50 ml/hour. The blood was drawn, and the results are: What should the nurse do first?

Appropriate Nursing Actions

• The client is admitted due to shortness of breath secondary to liver cirrhosis. Upon assessment, the client’s abdominal girth has been increasing for the past 2 days. The vital signs are temp 97 degrees Fahrenheit, RR 28 breaths/minute, HR 115 beats per minute, BP 150/80 mm Hg and 88% oxygen saturation in room air. Based on the assessment data, what are the appropriate nursing actions? Select all that apply.

Intervention Effectiveness

• The client is admitted due to shortness of breath secondary to liver cirrhosis. Upon assessment, the client’s abdominal girth is continuously getting bigger for the past 2 days. The vital signs are temp 97 degrees Fahrenheit, RR 28 breaths/ minute, HR 115 beats per minute, BP 150/80 mm Hg and 88% oxygen saturation in room air. The nurse did the following interventions:

For each finding, select whether the finding indicates the intervention was effective, ineffective or unrelated:

Assessment – Fluid Volume Excess

• A client is admitted to the emergency department due to episodes of shortness of breath and inability to walk due to edema in his lower extremities. Their spouse verbalized that this has been happening for the past 2 weeks. Based on the data provided, the priority nursing diagnosis is “fluid volume excess related to systemic alterations.” Which assessment data provides evidence to support this diagnosis?

The registered nurse is delegating client assignments to unlicensed assistive personnel. Which client can be safely delegated to the unlicensed assistive personnel (UAP)?

Clinical Conditions

• Which clinical conditions can cause fluid volume excess? Select all that apply.

Expected Findings

• The nurse anticipates which assessment findings of a client that has fluid volume excess? Select all that apply.

Prioritization and Delegation

• The registered nurse is delegating client assignments to unlicensed assistive personnel. Which client can be safely cared for by the unlicensed assistive personnel (UAP)?

Nursing Care: Altered Electrolyte Balance

Prepare: The Nursing Care of Altered Electrolyte Balance

Renal Function and Electrolytes

• A client's kidneys are retaining increased amounts of sodium. While planning care, the nurse anticipates that the kidneys are also retaining which other substances? Select all that apply.

Electrolyte Homeostasis

• A nurse is working on a medical-surgical unit and caring for a client with a nasogastric tube (NGT). The nursing policy and procedure reflects that irrigation of nasogastric tubes is once every 8 hours. To maintain homeostasis, which of the following solutions does the nurse anticipate will be prescribed to irrigate the NGT?

Electrolytes in Gastric Contents

• The nurse aspirates 40 mL of undigested formula from the client's nasogastric tube (NGT). Before administering an intermittent tube feeding, what should the nurse do with aspirate?

Self-Check: Nursing Care – Electrolyte Imbalance

• Most body systems are impacted by electrolytes. Since many assessment findings can be found with multiple electrolyte imbalances, it is important that the nurse consider the entire clinical picture, including risk factors and behaviors, in addition to assessment findings.

Self-Check: Recognized Cues of Hypocalcemia

• After completing a client's assessment, the nurse suspects hypocalcemia. Which clinical manifestations support the nurse’s hypothesis? Select all that apply.

Self-Check: Treating Hypocalcemia Induced Muscle Spasms

• When providing education to a client with hypocalcemia, which nursing actions could help reduce muscle spasms?

Self-Check: Dietary Sources of Phosphate

• A client has a phosphate level of 1.2 mg/dL. Which assessment finding should the nurse follow-up on immediately?

Reflect: The Nursing Care of Altered Electrolyte Balance

Recognizing Cues – Calcium and Phosphate

• Which factors in the health care provider’s note indicate this client is at risk for an electrolyte imbalance(s)? Select all that apply.

Analyzing Cues – Calcium and Phosphate

• A female, older adult client has routine labs drawn during their annual examination. The nurse is reviewing the results. Which results should the nurse report immediately to the health care provider? Select all that apply.

Prioritizing Hypotheses – Calcium and Phosphate

• Based on the laboratory results, for which conditions is this client at risk? For each condition, place a mark to indicate at risk or not at risk.

Generating Solutions – Calcium and Phosphate

• For each health care provider prescription listed below, indicate if it is indicated, nonessential, or contraindicated for treating the client’s osteoporosis and electrolyte imbalance.

Taking Action – Calcium and Phosphate

• Which information should the nurse include when providing education to the client with a new prescription for alendronate? Select all that apply.

Evaluating Outcomes – Calcium and Phosphate

• One month after the client began treatment for osteoporosis, the nurse is reviewing her laboratory results. For each result, specify if the value indicates the client’s condition has improved, not changed, or declined.

Prioritizing Hypotheses – Electrolyte Imbalance

• After reviewing the Nurse’s Notes, select the highest priority alteration in electrolytes suggested by the current cues (center column), the top two (2) cues/evidence supporting that electrolyte imbalance, and the top two (2) client conditions that support that electrolyte imbalance.

Hypophosphatemia

• The nurse reviews a client's laboratory report and notes that the serum phosphate level is 2 mg/dL. Which client factors most likely caused this serum phosphate level? Select all that apply.

Sodium Imbalance (hyper/hypo)

Prepare: Sodium Imbalance

Risk Factors

• Which of the following clients are most at risk for developing a sodium imbalance? Select all that apply.

Hypernatremia

• The nurse is caring for a client with severe hypernatremia. Which of the following findings would the nurse anticipate to see? Select all that apply.

Hyponatremia

• Which of the following is a contributing factor of hyponatremia?

Self-Check: Fluid Replacement

• Identifying the correct fluid replacement is key to appropriate interventions for clients with sodium imbalances. Label each fluid with the appropriate group.

Self-Check: Hyponatremia Findings

• The nurse is assessing Peggy upon admission. Which findings should the nurse expect? Select all that apply.

Self-Check: Admission Assignment

• Peggy is being admitted with new-onset confusion due to her hyponatremia. The nurse is attempting to assign Peggy to a room on the medical-surgical floor. Which action is most applicable? In which room should the nurse place Peggy?

Self-Check: Intervention

• The nurse recognizes that John’s sodium level is 150 mEq/L upon admission. He is currently lethargic. Which intervention would be most appropriate to initiate first?

Self-Check: Assessment

• After initiating intravenous (IV) fluids, the nurse is preparing to administer prescribed medications to John and is allowing a student nurse to assist her. Which statement made by the student nurse requires immediate intervention by the nurse?

Reflect: Sodium Imbalances

Dehydration Assessment

• The nurse is completing her assessment on John with the assistance of the student nurse. The nurse asks the student how to assess for dehydration on John. What is the best response by the student? Select all that apply.

Delegation

• There are many tasks that Peggy and John may need assistance with while in the hospital. Identify which tasks can be completed by the registered nurse (RN), licensed practical/vocational nurse (LPN/LVN), or the unlicensed assistive personnel (UAP). Note: Some colleagues may be able to complete more than one task.

Seizure Precautions

• The nurse recognizes that Peggy is at risk for seizures due to her hyponatremia. What equipment should the nurse prepare for Peggy’s room to initiate seizure precautions? Select all that apply

Priority Intervention

• Due to Peggy’s hyponatremia, a 3% sodium chloride fluid was initiated 24 hours ago to correct her sodium level of 128 mEq/L. New test results have just been reported, and Peggy’s latest sodium level is 149 mEq/L. Which of the following is the priority nursing intervention?

Therapeutic Communication

• Peggy is discussing her medications with the nurse. She mentions that she is not going to take her hydrochlorothiazide (HCTZ) anymore because of the recent issues with her sodium level. Which statement by the nurse is most appropriate?

Sodium Imbalances and Safety

• Both John and Peggy are high fall risks due to their sodium imbalances. From the list below, identify the potential safety concerns in a private hospital room. Select all that apply.

Diet Education

• John is discussing a low sodium diet with his wife. Which of the following statement indicates John needs further education?

New Admission Priorities

• The nurse is preparing to admit a new post-operative client from the recovery room. The nurse receives in report the client is restless and complaining of a headache and muscle weakness. The client’s labs are below. Which prescribed intervention is most appropriate to initiate first?

Potassium Imbalance (hyper/hypo)

Prepare: Potassium Imbalance

Risk Factors

• Which clients are at risk for developing a potassium imbalance? Select all that apply.

Manifestations of Hypokalemia

• Which manifestation is associated with hypokalemia?

Routes of Administration

• Which routes of administration are available for potassium chloride (KCl) supplements?

Self-Check: Diet Choices

• Which foods are rich in potassium? Select all that apply.

Self-Check: EKG Manifestations

• Which electrocardiogram (ECG) tracing is more closely related to hyperkalemia?

Self-Check: Hyperkalemia Treatment

• Which prescriptions will lower potassium levels? Select all that apply.

Self-Check: IV Treatments

• The nurse received a prescription for intravenous (IV) potassium chloride (KCl) for Kyle. A student nurse accompanies the nurse into the room. Which action by the student nurse requires immediate intervention?

Self-Check: Prescription Evaluation

• A client arrives to the emergency department (ED) with a serum potassium level of 2.8 mEq/L. The nurse should immediately alert the health care provider to which prescription medication taken by the client?

Reflect: Potassium Imbalances

Delegation

• Mary’s potassium level is 5.7 mEq/L. Which prescription should the nurse delegate to the LPN/LVN assisting with Mary’s care?

Diet Teaching

• Mary is preparing for discharge and is discussing her nutritional needs with a registered dietitian. Which statement made by Mary requires further education?

Nursing Diagnosis: Potassium Imbalance

• Which nursing diagnosis is the highest priority for Arthur?

Treatment: Potassium Imbalance

• Which prescription medication would the nurse anticipate Arthur being discharged home with?

Potassium and Digoxin

• Which manifestations alert the nurse to digoxin toxicity in a client with hypokalemia? Select all that apply.

Nursing Actions

• The nurse is attending to Kyle, who remains lethargic. His most recent potassium level is 2.9 mEq/L, and the health care provider has prescribed an oral potassium chloride (KCl) supplement. Which action by the nurse is most appropriate?

Appropriate Delegation

• There are many tasks to accomplish with the clients on the medical surgical floor. Indicate which tasks can be appropriately delegated to which colleagues.

Kyle’s Improvement

• Kyle’s nasogastric (NG) tube has been discontinued because of his increasing alertness and ability to safely handle oral medications and liquids. His most recent potassium level is 3.4 mEq/L. The health care provider has advanced Kyle’s diet to a regular diet. Which meal options are most appropriate for Kyle? Select all that apply.

Magnesium Imbalance (hyper/hypo)

Prepare: Magnesium Imbalances

Risk Factors

• Which clients are at risk for developing a magnesium imbalance? Select all that