NR 324 Week 1 EDAPT_Altered Fluid and Electrolyte Balance

Poor skin turgor upon assessment 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? Powerlessness Fluid volume deficit Knowledge deficit Fluid volume excess Self-Check: Priorities – Fluid Balance Excess In which order should the nurse complete these actions after admitting a client experiencing shortness of breath? 1. Introduce yourself to the client and identify the client using two identifiers. 2. Elevate the head of the bed and administer oxygen 2 LPM via nasal cannula. 3. Check creatinine level and blood pressure. 4. Check the medication using the 10 rights of medication administration and administer Furosemide 40 mg IVP for one dose. 5. Monitor the urine output and blood pressure. 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”. Fluid Balance and Disease Management The nurse identifies that clients with which clinical conditions require hypotonic IV fluids? Select all that apply. Heart failure Syndrome of inappropriate anti-diuretic hormone secretion Diabetes insipidus Diabetic ketoacidosis Pleural effusion Labs and Fluid Balance Which assessment findings indicate a client is experiencing altered fluid balance? Select all that apply. Serum osmolality 285 mOsm/kg Sodium level 140 meq/L Calcium 9 mg/dl Hematocrit 20% Urine osmolality (random) 2000 mOsm/kg 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. Serum osmolality 290 mOsm/kg Urine specific gravity 1.010 Hematocrit 25% Serum sodium 150 meq/L Hemoglobin 7.5 g/dL Fluid Balance and Electrolytes Which nursing interventions are appropriate for a client who has dilutional hyponatremia secondary to heart failure? Select all that apply. Give diuretics as ordered Slowly transfer from bed to chair Suggest fluid restriction Hold blood pressure medications Consider seizure precautions 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. albuterol lactulose bumetanide lisinopril digoxin 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 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