Ch. 39: Fluid, Electrolyte, and Acid-Base Balance

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: a) 100 gtt/min b) gtt/min = milliliters per hour × drop factor (gtt/mL) time (60 min) c) 60 gtt/min d) 600 gtt/min e) 160 gtt/min

100 gtt/min Explanation: 100gtt/min is the correct rate. 1000 mL divided by10 hours= 100 mL per hour x 60 gtt/minute, divided by 60 minutes.

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? a) 12 cm H2O b) 3.5 cm H2O c) 5 cm H2O d) 9.5 cm H2O

12 cm H2O Explanation: The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? a) 50 gtt/min b) 20 gtt/min c) 40 gtt/min d) 30 gtt/min

50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

What is the lab test commonly used in the assessment and treatment of acid-base balance? a) Urinalysis b) Complete blood count c) Chemistry I d) Arterial blood gas

Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? a) Milk b) Banana c) Yogurt d) Turkey

Banana Explanation: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level? a) Fluid volume excess b) Tetany c) Pulmonary embolus d) Cardiac dysrhythmias

Cardiac dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? a) Hypernatremia b) Hyperchloremia c) Hypokalemia d) Hypomagnesemia

Hypokalemia Explanation: Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea

Which client has more extracellular fluid? a) Adult woman b) Female school-age child c) Adolescent man d) Newborn

Newborn Explanation: Newborns have more extracellular fluid than intracellular fluid.

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation? a) Notify the primary care provider immediately for possible fluid overload. b) No intervention is necessary as this is a normal finding with IV infusion. c) Notify the primary care provider immediately because these are signs of speed shock. d) Check all clamps on the tubing and check tubing for any kinking.

Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear but some crackles in the bases are now auscultated, notify the primary care provider immediately. The client may be exhibiting signs of fluid overload. Be prepared to tell the health care provider what the past intake and output totals were, as well as the vital signs and pulse oximetry findings of the client.

Which of the following is not true regarding magnesium? a) Up to 60% of magnesium is in bone. b) The liver regulates magnesium levels by breaking down the ion when serum levels are low. c) Normal serum magnesium level ranges from 1.4 to 1.74 mEq/L. d) Magnesium is important in regulating neuromuscular function and cardiac activity.

The liver regulates magnesium levels by breaking down the ion when serum levels are low. Explanation: The kidneys regulate magnesium levels by reabsorbing the ion when serum levels are low and excreting it when serum levels are high.

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use a(an) a) Central venous access b) Winged infusion needle c) Intermittent infusion device d) 18-gauge needle

Winged infusion needle Explanation: Winged infusion needles are short, beveled needles with plastic flaps or wings. They may be used for short-term therapy or when therapy is given to a child or infant.

Potassium is needed for neural, muscle, and: a) cardiac function. b) auditory function. c) optic function. d) skeletal function.

cardiac function. Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a) metabolic acidosis b) cardiac irregularities c) muscle weakness d) increased intracranial pressure (ICP)

cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias

A decrease in arterial blood pressure will result in the release of: a) insulin. b) renin. c) thrombus. d) protein.

renin. Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

The primary extracellular electrolytes are: a) magnesium, sulfate, and carbon. b) phosphorous, calcium, and phosphate. c) sodium, chloride, and bicarbonate. d) potassium, phosphate, and sulfate.

sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: a) total parenteral nutrition. b) volume expander. c) blood transfusion therapy. d) cellular hydration.

total parenteral nutrition. Explanation: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? a) "I was breathing so fast because I was so anxious and in so much pain." b) "I've had a GI virus for the past 3 days with severe diarrhea." c) "I've been taking antacids almost every 2 hours over the past several days." d) "I've had a fever for the past 3 days that just doesn't seem to go away."

"I've been taking antacids almost every 2 hours over the past several days." Explanation: Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? a) 120 drops/mL b) 90 drops/mL c) 60 drops/mL d) 30 drops/mL

60 drops/mL Explanation: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL)

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? a) Constipation related to immobility b) Risk for Infection related to inadequate personal hygiene c) Pain related to surgical incision d) Acute Confusion related to cerebral edema

Acute Confusion related to cerebral edema Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? a) A peripheral venous catheter inserted to the antecubital fossa b) An implanted central venous access device (CVAD) c) A peripheral venous catheter inserted to the cephalic vein d) A midline peripheral catheter

An implanted central venous access device (CVAD) Explanation: Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? a) Use regular gum and hard candy. b) Use an alcohol-based mouthwash to moisten your mouth. c) Eat crackers and bread. d) Avoid salty or excessively sweet fluids.

Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst

What food would the nurse provide for a client who has hypokalemia? a) Bread b) Canned vegetables c) Cheese d) Bananas

Bananas Explanation: Hypokalemia is a below normal potassium level. Bananas are high in potassium. Adding bananas to the diet can help increase the serum potassium level. Canned vegetables, cheese, and bread do not have a high potassium content.

The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients? a) Cardiac volume intolerance b) Increased renal blood flow c) Increase in nephrons in the kidneys d) An increased sense of thirst

Cardiac volume intolerance Explanation: The elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. The elderly typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.

Which is a common anion? a) Magnesium b) Chloride c) Calcium d) Potassium

Chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? a) Ensure that the prescribed solution is clear and transparent. b) Avoid replacing IV solution every 24 hours. c) Select a primary tubing of about 37 inches (94 cm) long. d) Use half-instilled IV solutions before infusing a new one.

Ensure that the prescribed solution is clear and transparent. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded? a) Sips of water b) Fruit consumption c) Parenteral fluids d) Frozen fluids

Fruit consumption Explanation: Any water consumption must be recorded in order to closely monitor a patient who has congestive heart failure. Many of these patients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L Potassium: 3.2 mEq/L Calcium: 4.4 mEq/L Magnesium: 1.6 mEq/L Chloride: 100 mEq/L Phosphate: 1.8 mEq/L Based on these levels, the nurse would identify which imbalance? a) Hypermagnesemia b) Hypokalemia c) Hypercalcemia d) Hyponatremia

Hypokalemia Explanation: All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L). Therefore the client has hypokalemia.

Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L. For what manifestations will you be alert? a) Diminished cognitive ability and hypertension b) Muscle weakness, fatigue, and constipation c) Muscle weakness, fatigue, and dysrhythmias d) Nausea, vomiting, and constipation

Muscle weakness, fatigue, and dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? a) Chloride b) Sodium c) Phosphorous d) Potassium

Potassium Explanation: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a) a 60-year-old who is 3 days post-myocardial infarction and has been stable. b) a 47-year-old who had a colon resection yesterday and is reporting pain c) a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today d) a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Explanation: Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old.

Major control over the extracellular concentration of potassium within the human body is exerted by: a) aldosterone. b) albumin. c) testosterone. d) progesterone.

aldosterone. Explanation: Aldosterone exerts major control over the extracellular concentration of potassium. It also enhances renal secretion of potassium.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? a) nausea and vomiting b) distended neck veins c) muscle twitching d) fingerprinting over sternum

distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: a) non-electrolytes. b) electrolytes. c) colloid solution. d) interstitial fluid.

electrolytes. Explanation: The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have non-electrolytes, colloid solution, or interstitial fluid restored

Edema happens when there is which fluid volume imbalance? a) extracellular fluid volume excess b) extracellular fluid volume deficit c) water excess d) water deficit

extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: a) hypocalcemia. b) hypokalemia. c) hypoglycemia. d) hypothyroidism.

hypokalemia. Explanation: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: a) hypernatremia. b) hyponatremia. c) hypokalemia. d) hyperkalemia

hyponatremia. Explanation: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of: a) rapid fluid administration. b) a systemic blood infection. c) an infiltration. d) phlebitis.

phlebitis. Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension.

A woman age 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: a) an access route to replace fluids in combination with blood products. b) an access route to administer medications intravenously. c) intravenous fluids to be administered on an outpatient basis. d) replacement of fluids for those lost from vomiting and diarrhea.

replacement of fluids for those lost from vomiting and diarrhea. Explanation: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

A student has joined the marching band at his high school. The band begins practicing outside in August. This student and other band members need to be instructed that: a) this exercise will have a minimal effect on fluid and electrolytes. b) the hot weather will assist in building them up for the marching season. c) the band members should drink large amounts of water. d) endurance increases as time increases on the field with heat.

the band members should drink large amounts of water. Explanation: Caution children and adolescents against the potential dangers of excessive exercise without adequate fluid replacement, especially in hot weather, because muscle damage and fluid and electrolyte imbalances can occur

When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. What is the most likely complication that has occurred? a) infiltration b) speed shock c) sepsis d) thrombus

thrombus Explanation: Phlebitis and thrombus present as local acute tenderness, redness, warmth, and slight edema of the vein above the site. Sepsis manifests as a red and tender insertion site with fever, malaise, and other vital sign changes. Infiltration or the escape of fluid into the subcutaneous tissue manifests as swelling, pallor, coldness, or pain around the infusion site and significant decrease in the flow rate. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.

The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which of the following statements made by students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply. a) "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." b) "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." c) "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." d) The adrenal glands regulate blood volume by secreting aldosterone." e) "The kidneys react to hypovolemia by stimulating fluid retention."

• "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." • "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." • The adrenal glands regulate blood volume by secreting aldosterone." • "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." Explanation: The heart and blood vessels react to hypovolemia by stimulating fluid retention rather than the kidneys. The other statements made by the students are correct.

What nursing interventions would be appropriate for a patient diagnosed with deficient fluid volume? (Select all that apply.) a) Nutrition management b) Intravenous therapy c) Hypervolemia management d) Electrolyte management e) Monitoring edema f) Fluid restriction

• Nutrition management • Intravenous therapy • Electrolyte management Explanation: If a patient is at a fluid volume deficit intravenous therapy may be ordered by the primary care provider to replenish fluids and electrolytes, warranting fluid and electrolyte management. Nutrition management may help to increase and maintain electrolyte levels by adding foods high in certain electrolytes to the diet. Hypervolemia refers to fluid volume excess. Fluid restriction would be contraindicated because the patient is already at a deficit. Edema would be monitored in the case of fluid volume excess.