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Nursing Assessment of Fluid and Electrolyte Imbalances

  • Chronic diseases

  • Acute conditions

  • Medications

  • Age:

    • Very old or very young

  • Inability to access food and fluids

    • Physical Assessment:

    • Skin

    • Mucus membranes

    • Eyes

    • Fontanels (infants)

    • Cardiovascular system

    • Respiratory system

    • Neurologic

    Clinical Measurements:

    • Daily weights:

      • At the same time each day

      • Wearing the same or similar clothing

      • On the same scale

    • Vital signs

    • Fluid intake/output

    Intake to be Recorded:

    • Oral fluids

    • Foods that are or become liquid at room temperature

    • Tube feedings

    • Parenteral feedings

    • IV medications

    • Catheter or tube irrigation

    Output to be Recorded:

    • Urinary output

    • Vomitus and liquid feces

    • Tube drainage

    • Wound and Fistula Drainage

     

Questions on Nursing Assessment of Fluid and Electrolyte Imbalances

Correct Answer is A

Explanation

<p>Increasing dietary intake of potassium is not helpful for a client who has hypernatremia. Potassium is another electrolyte that plays a role in fluid balance and nerve function, but it is not affected by hypernatremia. In fact, increasing potassium intake may worsen the condition by causing further dehydration or hyperkalemia (high potassium levels)</p>

Correct Answer is ["A","B","C","E"]

Explanation

<p>Elevating the head of the bed is a fourth action that the nurse should take because it improves respiratory function and reduces pulmonary congestion. The nurse should elevate the head of the bed to at least 30 degrees or more, depending on the client&#39;s comfort and tolerance. The nurse should also monitor the client&#39;s oxygen saturation, breath sounds, and dyspnea.</p>

Correct Answer is A

Explanation

<p>Having a headache and dizziness is a sign of cerebral dehydration and a negative outcome of IV fluid therapy. Headache and dizziness are common symptoms of dehydration that result from reduced blood flow to the brain and increased osmolality of the blood. When IV fluids are administered, they improve the cerebral perfusion and osmotic balance and relieve the headache and dizziness.</p>

<p>A client who has chronic kidney disease should not use salt substitutes instead of table salt because they often contain potassium chloride, which can also increase the potassium level in the blood and cause hyperkalemia. Salt substitutes are not recommended for clients who have kidney disease or

<p>Crackles in the lungs are not a sign of fluid volume deficit, but rather a sign of fluid volume excess or pulmonary edema. Crackles are abnormal lung sounds that indicate fluid accumulation in the alveoli or air sacs of the lungs. Fluid volume deficit does not cause fluid accumulation in the lung
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