Fluid and Electrolyte Balances

Every question here, with the answer

1. A nurse is admitting a 9-month-old infant with a three-day history of vomiting and diarrhea. The infant has sunken eyes and a depressed anterior fontanelle, and the orders include only a clear liquid diet with no baseline laboratory testing. What is the nurse’s best action?

   1. Contact the provider to discuss hydration status and recommend a basic metabolic panel and peripheral IV.
   2. Begin teaching the family about decreasing calcium intake and increasing phosphorus intake.
   3. Request sodium and fluid restriction because the infant is likely hypervolemic.
   4. Continue the clear liquid diet and reassess in 24 hours.

   Answer: Contact the provider to discuss hydration status and recommend a basic metabolic panel and peripheral IV.

   The infant’s vomiting, diarrhea, sunken eyes, and depressed fontanelle are concerning for dehydration. The section’s example supports escalating concerns to the provider and recommending laboratory monitoring and IV access when dehydration may require IV fluids.

2. A nurse is assessing a patient at risk for fluid volume overload. Which findings would support fluid volume overload? Select all that apply.

   1. Dyspnea with crackles in the lung fields
   2. Ascites
   3. Pitting edema
   4. No wet diapers for three hours or more
   5. Crying without tears

   Answer: Dyspnea with crackles in the lung fields, Ascites, Pitting edema

   Pitting edema, ascites, dyspnea, and crackles are findings associated with fluid volume overload. Crying without tears and no wet diapers for three hours or more are possible signs of dehydration in infants and young children, not overload.

3. A patient has a high serum sodium level and new confusion. Which explanation best supports the nurse’s concern about neurologic changes?

   1. High sodium moves fluid into the intracellular space, causing all cells to swell equally.
   2. High sodium pulls fluid out of the intracellular space, and brain cells are sensitive to these shifts.
   3. Sodium mainly affects bone density and does not influence fluid distribution.
   4. Sodium is found mostly in the intracellular fluid, so neurologic effects are unlikely.

   Answer: High sodium pulls fluid out of the intracellular space, and brain cells are sensitive to these shifts.

   The section explains that water follows sodium: high serum sodium pulls fluid out of cells. Brain cells are particularly sensitive to these fluid shifts, so confusion is a concerning sign.

4. A patient with hypokalemia has an order for potassium replacement. Before administering it, which assessment is most important for the nurse to confirm?

   1. The patient has a low-phosphorus diet.
   2. The patient has signs of pitting edema.
   3. The patient has decreased calcium intake.
   4. The patient has adequate urine output.

   Answer: The patient has adequate urine output.

   Potassium is excreted by the kidneys, so inadequate urine output increases the risk of potassium accumulation. The section emphasizes confirming adequate urine output before potassium replacement.

5. A nurse is assessing a patient whose symptoms suggest hypocalcemia. Which findings are consistent with hypocalcemia? Select all that apply.

   1. Muscle cramps
   2. Involuntary twitching of the facial muscle when the facial nerve is tapped
   3. Numbness and tingling of the lips, tongue, hands, and feet
   4. Involuntary muscle contractions
   5. Constipation and skeletal muscle weakness

   Answer: Muscle cramps, Involuntary twitching of the facial muscle when the facial nerve is tapped, Numbness and tingling of the lips, tongue, hands, and feet, Involuntary muscle contractions

   Hypocalcemia is associated with paresthesia, muscle cramps, tetany, and Chvostek’s sign. Constipation and skeletal muscle weakness are listed as symptoms of hypercalcemia, not hypocalcemia.

6. A patient with heart failure says they prefer using traditional remedies and are hesitant about dietary and fluid recommendations. Which nursing response best supports adherence to the care plan?

   1. Focus only on prescribed medications because cultural practices do not affect fluid balance education.
   2. Acknowledge the patient’s cultural preferences and integrate safe traditional practices when possible.
   3. Tell the patient to stop all traditional practices before discussing diet changes.
   4. Avoid discussing sodium and fluid intake until the patient stops using traditional remedies.

   Answer: Acknowledge the patient’s cultural preferences and integrate safe traditional practices when possible.

   The section emphasizes that respecting cultural preferences can make patients more receptive to education about diet and fluid recommendations. Integrating safe traditional practices supports adherence rather than dismissing the patient’s beliefs.