chapter 40
The narrow range of normal pH is achieved through three major homeostatic regulators of hydrogen ions:
(1) chemical buffer systems (2) respiratory mechanisms (3) renal mechanisms.
what percetage of water does a healthy person have in their body?
50-60%
A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. A. "Try to drink at least six to eight glasses of water each day." B. "Try to limit your fluid intake to 1 quart of water daily." C. "Limit sugar, salt, and alcohol in your diet." D. "Report side effects of medications you are taking, especially diarrhea." E. "Temporarily increase foods containing caffeine for their diuretic effect." F. "Weigh yourself daily and report any changes in your weight."
A. "Try to drink at least six to eight glasses of water each day." C. "Limit sugar, salt, and alcohol in your diet." D. "Report side effects of medications you are taking, especially diarrhea." F. "Weigh yourself daily and report any changes in your weight."
A nursing instructor is explaing the difference between infiltration and phlebitis to a student, whisch statement is more appropriate? A. "infiltration occurs when IV fluid escapes into the tissue, while plebitis is inflammation of the veins" B. "infiltration is the inflammation of the vein, while phlebitis is localized irritation" C. "infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed" D. "infiltration occurs when an IV is properly placed, and phlebitis indicates circulatory overload"
A. "infiltration occurs when IV fluid escapes into the tissue, while plebitis is inflammation of the veins"
A nurse on the IV team is conducting an in-service education program about complications of IV therapy. which of the following statements by an attendee indicatex an understanding of the manifestation of infiltration? A. "the temperature around the IV site is cooler." B. "the rate of the infusion increases." C. "The skin at the IV site is red." D. "the IV dressing is damp." E. "the tissue around the venipuncture site is swollen."
A. "the temperature around the IV site is cooler." D. "the IV dressing is damp." E. "the tissue around the venipuncture site is swollen."
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? A. 1 unit over 2 to 3 hours, no longer than 4 hours B. 200 mL/hr C. As fast as the client can tolerate D. 75 mL/hr for the first 15 minutes, then 200 mL/hr
A. 1 unit over 2 to 3 hours, no longer than 4 hours
Total parenteral nutrition is hypertonic. What is the percentage of dextrose in these solutions? A. 50% dextrose B. 2.5% dextrose C. 5% dextrose D. 10% dextrose
A. 50% dextrose
What is the lab test commonly used in the assessment and treatment of acid-base balance? A. Arterial blood gas B. Complete blood count C. Urinalysis D. Basic metabolic panel
A. Arterial blood gas
a nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that whch actions are the nurses responsibilities related to the therapy? select all that apply A. Deciding the size of the IV catheter B. deciding the location of the IV catheter C. determing the amount of the IV solution D. administering the IV solution E. prescribing the kind of IV solution
A. Deciding the size of the IV catheter B. deciding the location of the IV catheter D. administering the IV solution
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? A. Decreased potassium levels B. Increased sodium levels C. Increased potassium levels D. Decreased oxygen levels
A. Decreased potassium levels
A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? A. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. B. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. C. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. D. Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.
A. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately.
a nurse is reveiwing the labratory test result for a client whohas an elevated temperature. the nurse should identify which of the following findings is a manifestation of dehydration? (select all that apply) A. HCT 55% B. blood osmolarity 260 m0sm/kg C. blood sodium 150 mEq/L D. urine specific gravity 1.035 E. blood creatine 0.6 mg/dL
A. HCT 55% C. blood sodium 150 mEq/L
A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? A. Remove the IV from the site and start at another location. B. Immediately notify the primary care provider. C. Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. D. Aspirate the catheter and attempt to flush again.
A. Remove the IV from the site and start at another location.
A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? A. Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. B. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. C. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. D. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.
A. Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? A. Start an IV of normal saline as prescribed. B. Allow nothing by mouth. C. Give the client a glass of orange juice with added sugar. D. Encourage fluid intake.
A. Start an IV of normal saline as prescribed.
a nurse on a medical surgeical unit is caring for a group of clients. the nurse should identify that which of the following clients is at risk for hypovolemia? A. a client who has nasogastric suctioning B. a client who has chronic constipation C. a client who has syndrome of inappropriate antidiuretic hormone D. a client who took a toxic dose of sodium bicarbonate antiacid
A. a client who has nasogastric suctioning
What nursing diagnosis would the nurse make based on the effects of fluis and electrolytes imbalance of human functioning A. acute confusion related to cerebral adema B. pain related to surgical incision C. constipation related to immobility D. risk for infection related to inadequate personal hygeine
A. acute confusion related to cerebral adema
What is common anion? A. Chloride B. magnesium C. potassium D. Calcium
A. chloride
a nurse is reveiwinng the medical record of a client who has hypacalcemia. the nurse should identify which of the following findings as a risk factor for development of this electrolyte embalance? A. chrohn's disease B. postoperative following appendectomy C. history of bone cancer D. hyperthyroidism
A. chrohn's disease
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing: A. fluid overload. B. anaphylaxis. C. pulmonary embolism. D. allergic reaction.
A. fluid overload.
a nurse is planning care for a client who has hypernatremia. which of the following actions should the nurse include in the plan of care? A. infuse hypotonic IV fluids B. implement a fluid restriction C. increase sodium intake D. administer sodium polystyrene sulfonate
A. infuse hypotonic IV fluids
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding? A. pH: 7.60; PaCO2: 64; HCO3: 42 B. pH: 7.32; PaCO2: 26; HCO3: 18 C. pH: 7.32; PaCO2: 28; HCO3: 24 D. pH: 7.28; PaCO2: 52; HCO3: 32
A. pH: 7.60; PaCO2: 64; HCO3: 42
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.
A. total parenteral nutrition.
___________ occur when the carbonic acid or bicarbonate levels become disproportionate.
Acid-base imbalances
is the condition characterized by an excess of H ions or loss of base ions (bicarbonate) in ECF in which the pH falls below 7.35.
Acidosis
Requires energy for the movement of substances through a cell membrane, against the concentration gradient, from an area of lesser solute concentration to an area of higher solute concentration.; Adenosine triphosphate (ATP), which is stored in all cells, supplies energy for solute movement in and out of the cell.
Active Transport (Pumping Uphill)
Substance that can accept or trap H+ ions; E.g. Bicarbonate ion.
Alkali (base)
occurs when there is a lack of H ions or a gain of base (bicarbonate) and the pH exceeds 7.45
Alkalosis
The nurse is demonstrating how to insert an IV catheter. which of the following statements by a nurse veiwing the demonstration indicates understanding of the procedure? A.: "I will thread the needle all the way into the vein until the hub rest against the insertion site after i see the flashbask of blood" B. " I will insert the needle into the clients skin at an angle of 10 to 30 degrees with the bevel up." C. " I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle." D. " I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location. "
B. " I will insert the needle into the clients skin at an angle of 10 to 30 degrees with the bevel up."
A nurse is care for a client recieving Dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr which of the following statements by the client should alert the nurse to suspect fluid overload? (select all that apply) A. " I feel lightheaded." B. "I feel as though my heart is racing." C. " i feel a little short of breathe." D. "the nurse technician told me that my blood pressure was 150/90" E. "i think my ankles are less swollen"
B. "I feel as though my heart is racing." C. " i feel a little short of breathe." D. "the nurse technician told me that my blood pressure was 150/90"
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? A. "Unfortunately, your own blood cannot be reinfused during surgery." B. "Let me refer you to the blood bank so they can provide you with information." C. "We now have artificial blood products, so giving your own blood is not necessary." D. "This surgery has a very low chance of hemorrhage, so you will not need blood."
B. "Let me refer you to the blood bank so they can provide you with information."
When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? A. 1 B. 2 C. 3 D. 4
B. 2
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. 5 cm H2O B. 3.5 cm H2O C. 9.5 cm H2O D. 12 cm H2O
B. 3.5 cm H2O
A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? A. Encourage foods and fluids with high sodium content. B. Administer oral K supplements as ordered. C. Caution the patient about eating foods high in potassium content. D. Discuss calcium-losing aspects of nicotine and alcohol use.
B. Administer oral K supplements as ordered.
A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? A. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. B. Keeping fluids readily available for the patient. C. Emphasizing the long-term outcome of increasing fluids when the patient returns home. D. Planning to offer most daily fluids in the evening.
B. Keeping fluids readily available for the patient.
A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: A. Kidneys B. Lungs C. Adrenal glands D. Blood vessels
B. Lungs
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. what acid base imbalance related to the loss of stomach acid doses the nurse observe on the arterial blood gas (ABG)? A. metabolic acidosis B metabolic Alkalosis C. respiratory acidosis D. respiratory alkalosis
B. Metabolic Alkalosis
a nurse on a medical-surgical unit is caring for a group of clients. for which of the following clients should the nurse expect a perscription for fluid restriction? A. a client who has a new diagnosis of adrenal insufficiency B. a client who has heart failure C. a client who is receiving treatment of diabetic ketoacidosis D. a client who has abdominal ascites
B. a client who has heart failure
a nurse is planning care for a client who has dehydration. which of the following actions should the nurse include? A. administer antuhypertensive on s hedule B. check the clients weight each morning C. notify the provider of a urine outout greater than 30 mL/hr D. encourage indipendent ambulation four times a day
B. check the clients weight each morning
a nurse is collecting data from a client who has hypercalcemia as a result of long term use of glucocurticoids. which of the following findings should the nurse expect? (selects all that apply) A. hyperreflexia B. confusion C. positive chvostek's sign D. bone pain E. nausea and vomiting
B. confusion D. bone pain E. nausea and vomiting
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. muscle twitching B. distended neck veins C. fingerprinting over sternum D. nausea and vomiting
B. distended neck veins
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? A. extracellular B. intracellular C. interstitial D. intravascular
B. intracellular
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? A. hypotonic B. isotonic C. hypertonic D. colloid
B. isotonic
A woman aged 58 years is suffering from food posioning after eating at a local restraunt, She has had nausea, vomiting,, and diarrhea for the past 12 hours. her bood pressure is 88/50 she is diapharetic. she requires: A.an access route to replace fluids in combinations with blood products B. replacement of fluids for those lost from vomiting and diarrhea C. intervenous fluids to be administered on an outpatient basis D. an access route to administer medication intervenously
B. replacement of fluids for those lost from vomiting and diarrhea
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? A. 3,500 mL/day B. 1,000 mL/day C. 2,500 mL/day D. 1,500 mL/day
C. 2,500 mL/day
A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? A. 1+ pitting edema B. 2+ pitting edema C. 3+ pitting edema D. 4+ pitting edema
C. 3+ pitting edema
The nurse is calculating an infusion rate for the following order: infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. what is the infusion rate? A. 73 mL/hr B. 23 mL/hr C. 83 mL/HR D. 13mL/hr
C. 83 mL/hr
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? A. Position the client on the left side. B. Elevate the client's head. C. Apply a warm compress. D. Apply antiseptic and a dressing.
C. Apply a warm compress.
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? A. ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. B. Bowel motility will be restored within 24 hours after beginning supplemental K+. C. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. D. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.
C. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? A. A pinched and drawn facial expression B. Deep, rapid respirations. C. Moist crackles heard upon auscultation D. Tachycardia
C. Moist crackles heard upon auscultation
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? A. Notify the primary care provider immediately because these are signs of speed shock. B. Place the client in the Trendelenburg position to keep the client's airway open. C. Notify the primary care provider immediately for possible fluid overload. D. Check all clamps on the tubing and check tubing for any kinking.
C. Notify the primary care provider immediately for possible fluid overload.
The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the prioritynursing action? A. Call for assistance. B. Assess for visible rash. C. Stop the transfusion. D. Assess oxygen levels.
C. Stop the transfusion.
Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? A. Respiratory acidosis B. Respiratory alkalosis C. acidosis D. Metabolic alkalosis
C. acidosis
Edema happens when there is which fluid volume imbalance? A. water excess B. extracellular fluid volume deficit C. extracellular fluid volume excess D. water deficit
C. extracellular fluid volume excess
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. hypothyroidism. B. hypocalcemia. C. hypokalemia. D. hypoglycemia.
C. hypokalemia.
a nurse recieves a labratory report for a client indicating a potassium level of 5.2 mEq/l. when notifying the provider, the nurse should expect which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. consulting with dietitician to increase intake of potassium C. initiating continuous cardiac monitoring D. preparing the client for gastric lavage
C. initiating continuous cardiac monitoring
A decrease in arterial blood pressure will result in the release of: A. thrombus. B. protein. C. renin. D. insulin.
C. renin
a decrease in arterial blood pressure will result in the release of A. protein B. thrombus C. renin D. insulin
C. renin
The primary extracellular electrolytes are: A. phosphorous, calcium, and phosphate B. Potassium, phosphate, and sulfate C. sodium, chloride, and biocarbinate D. magnesium, sulfate, and carbon
C. sodium, chloride, and biocarbinate
A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. nurse should expect which of the following findings? (select all that apply) A. Distended neck veins B. hyperthermis C. tachycardia D. syncope E. Decreased skin turgor
C. tachycardia D. syncope E. Decreased skin turgor
The narrow range of normal pH is achieved through three major homeostatic regulators of hydrogen ions
Chemical buffer systems Respiratory mechanisms Renal mechanisms
During new employhee orientation, a nurse is explaing how to prevent IV infections. which of the following statements by an orientee indicates understanding the preventive strategies? A. " I will leave the IV catheter in places after the client completes the course of IV antibiotics." B. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." C. " If my client needs to use the restroom, it would be safer to disconnect their IV infusion as long as I clean the injection port thuroughly with an antiseptic swab." D. " I will replace any IV catheter when I suspect contamination during insertion."
D. " I will replace any IV catheter when I suspect contamination during insertion."
he student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? A. "Fluid outside cells." B. "Fluid inside cells." C. "Watery plasma, or serum, portion of blood." D. "Fluid in the tissue space between and around cells."
D. "Fluid in the tissue space between and around cells."
The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate? A. "You only record urine output in an adult undergarment; you do not record diarrhea output." B. "Estimate the amount of fluid that you think was excreted into the undergarment." C. "We do not record fluids absorbed into undergarments." D. "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."
D. "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."
a nurse is providing education for a cliennt who has severe hypomagnesemia and is proscribed oral magnesium sulfate. which of the following information should the nurse include in the treatment? A. "avoid green leafy vegetables while taking this medication" B. "you should recieve a prescription for a thiazide diuretic to take with the magnesium." C. "you should eliminate whole grains from your diet until your magnesium level increases." D. "report diarrhea while taking this medication."
D. "report diarrhea while taking this medication."
A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. A. 5% dextrose in 0.9% NaCl B. 0.9% NaCl (normal saline) C. Lactated Ringer's solution D. 0.33% NaCl (⅓-strength normal saline) E. 0.45% NaCl (½-strength normal saline) F. 5% dextrose in Lactated Ringer's solution
D. 0.33% NaCl (⅓-strength normal saline) E. 0.45% NaCl (½-strength normal saline)
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 (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? A. Pulmonary embolus B. Tetany C. Fluid volume excess D. Cardiac dysrhythmias
D. Cardiac dysrhythmias
A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)? A. Removing a client's PICC in anticipation of the client's discharge B. Initiating a client's transfusion of packed red blood cells C. Deaccessing a client's implanted port D. Changing the dressing on a client's peripheral IV site
D. Changing the dressing on a client's peripheral IV site
A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action? A. Flush with 3-mL normal saline. B. Slow the rate of infusion by 50%. C. Attempt to aspirate. D. Discontinue the IV.
D. Discontinue the IV.
a nurse is collecting data froma client who is receiving IV therapy and reports pain in the arm,chills, and "not feeling well". the nurse notes warmth, edema, Iinduration, and red streaking on the clients arm close the the IV insertion site which of the following actions should the nurse plan to take first? A. Obtain a specimen for culture B. apply a warm compress C. administer analgesics D. Discontinue the infusion
D. Discontinue the infusion
A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? A.Recording intake and output. B. Testing skin turgor. C. Reviewing the complete blood count. D. Measuring weight daily.
D. Measuring weight daily.
A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? A. Reposition the extremity and raise the height of the IV pole. B. Apply pressure to the dressing on the IV C. .Pull the catheter out slightly and reinsert it. D. Put on gloves; remove the catheter
D. Put on gloves; remove the catheter
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? A. increased blood volume and extracellular overhydration B. blood volume and intracellular dehydration C. decreased blood volume and extracellular overhydration D. decreased blood volume and intracellular dehydration
D. decreased blood volume and intracellular dehydration
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? A. maintenance of blood volume B. removal of waste C. transportation of nutrients D. maintenance of cell size
D. maintenance of cell size
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 are indicative of: A. an infiltration. B. a systemic blood infection. C. rapid fluid administration. D. phlebitis.
D. phlebitis.
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? A. asking the client to pump their fist several times B. palpating the veins on the nondominant hand C. asking if the client is right or left handed D. placing the tourniquet on the upper arm for 2 minutes
D. placing the tourniquet on the upper arm for 2 minutes
Nursing interventions to prevent or correct fluid, electrolyte, and acid-base imbalances
Dietary Modification Modification of fluid intake, Medication administration, IV therapy, Blood and blood products replacement, Administration of PN Allaying anxiety as needed Appropriate patient and family teaching.
Caused by a loss of both water and solutes in the same proportion from the ECF space; As the interstitial space is depleted, its fluid becomes hypertonic, and cellular fluid is then drawn into the interstitial space, leaving cells without adequate fluid to function properly.; Result from the loss of body fluids, especially if fluid intake is decreased simultaneously.
Fluid Volume Deficit (Hypovolemia)
Excessive retention of water and sodium in ECF in near-equal proportions; may be a result of fluid overload (excess water and sodium intake
Fluid Volume Excess (Hypervolemia)
are vital to life, and adequate balance is imperative to maintain healthy functioning of the body.
Fluids and electrolytes
Serum sodium >145 mEq/L; Caused by excess water loss or an overall excess of sodium. ; Fluid deprivation, lack of fluid consumption (such as in patients who cannot perceive, respond to, or communicate thirst diarrhea, and excess insensible water loss (hyperventilation, burns) lead to excess sodium; Fluids move from the cells because of the increased extracellular osmotic pressure, causing them to shrink and leaving them without sufficient fluid; Cells of the central nervous system are especially affected, resulting in signs of neurologic impairment, including restlessness, weakness, disorientation, delusion, and hallucinations. Permanent brain damage, especially in children, can occur (
Hypernatremia
Serumphosphate >4.5 mg/dL or 2.6 mEq/L); Common causes are impaired kidney excretion and hypoparathyroidism; can result in tetany, anorexia, nausea, muscle weakness, and tachycardia
Hyperphosphatemia
Serum potassium <3.5 mEq/L; Potassium is the major intracellular electrolyte.; Potassium may be lost through vomiting, gastric suction, alkalosis, or diarrhea, or as the result of the use of diuretics; When the extracellular potassium level falls, potassium moves from the cell, creating an intracellular potassium deficiency; Sodium and hydrogen ions are then retained by the cells to maintain isotonic fluids.
Hypokalemia
Serum sodium <135 mEq/L; Caused by a loss of sodium or a gain of water.;Sodium may be lost through vomiting, diarrhea, fistulas, sweating, or as the result of the use of diuretics; The decrease in sodium causes fluid to move by osmosis from the less concentrated ECF compartment to the ICF space; This shift of fluid leads to swelling of the cells, with resulting confusion, hypotension, edema, muscle cramps and weakness, and dry skin; ) is manifested by signs of increasing intracranial pressure, which may include lethargy, muscle twitching, focal weakness, hemiparesis, and seizures; death may occur (Hinkle & Cheever, 2018).
Hyponatremia
Phosphorus is a critical element of all the body's tissues; serum phosphate <2.5 mg/dL or 1.8 mEq/L); can result from administration of calories to malnourished patients, alcohol withdrawal, diabetic ketoacidosis, hyperventilation, insulin release, absorption problems, and diuretic use; Manifestations include irritability, fatigue, weakness, paresthesias, confusion, seizures, and coma.
Hypophosphatemia
is associated with an excess of HCO3, and decrease in H+ ions, or both in the extracellular fluid (ECF). This may be the result of excessive acid losses or increase base ingestion or retention loss of stomach acid may result in this coondition
Metabolic Alkadosis
Mechanisms Responsible for Fluid and electrolyte Balance
Organs and Body Systems Osmosis Diffusion Active Transport Capillary Filtration
is when the carbon dioxide level is low and the pH is hgih
Respiratory alkalosis
Substance containing H+ that can be liberated or released; E.g. Carbonic acid.
acid
Acidity or alkalinity of a solution is determined by its concentration of hydrogen ions (H+).
acid base balance
Carbonic acid or bicarbonate levels become disproportionate.; When there is a single primary cause, these disturbances are known as respiratory acidosis or alkalosis and metabolic acidosis or alkalosis,
acid base imbalance
negative charge
anion
are laboratory tests commonly used to determine the adequacy of oxygenation and ventilation, as well as in the assessment and treatment of acid-base imbalance.; are obtained through analysis of an arterial blood sample.
arterial blood gases
bodies primary buffer system
biocarbonate
nerve impulse, blood clotting, muscle contraction, b12 absorption
calcium
Passage of fluid through a permeable membrane; Fluids move from an area of high pressure to one of lower pressure.; Results from the force of blood "pushing" against the walls of the capillaries.
capillary filtration
positive charge
cations
a common anion, which is a negatively charges ion
chloride
maintains osmotic pressure in blood, produces hydrochlroic acid
chloride
what labratory studies would you do?
complete blood count urine pH specific gravity
Nursing interventions to prevent or correct fluid, electrolyte, and acid-base imbalances include
dietary modification, modification of fluid intake, medication administration, IV therapy, blood and blood products replacement, and administration of PN.
Solutes to move freely throughout a solvent.; The solute moves from an area of higher concentration to an area of lower concentration; Oxygen and carbon dioxide exchange in the lung's alveoli and capillaries occurs by
diffusion
substances that ca =n break into particals called ions
electrolytes
Patient education is essential for independence in self-care related to
fluid, electrolyte, and acid-base imbalance.
Body fluids must maintain an acid-base balance to sustain
health, homeostasis, and life
Maintaining _________________ of fluid volume and electrolytes is essential to healthy body functioning. Almost every organ and system in the body helps in some way to maintain fluid _____________.
homeostasis; homeostasis
Serum calcium >10.1 mg/dL, ionized calcium >5.1 mg/dL; Two major causes of _____ are cancer and hyperparathyroidism; Manifestations of ______ include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech.
hypercalcemia
Serum chloride >106 mEq/L); can result from metabolic acidosis, head trauma, increased perspiration, excess adrenocortical hormone production, and decreased glomerular filtration; Signs and symptoms include tachypnea, weakness, lethargy, diminished cognitive ability, hypertension, decreased cardiac output, dysrhythmias, and coma.
hyperchloremia
Serum potassium >5 mEq/L; Excess potassium may result from renal failure, hypoaldosteronism, or the use of certain medications such as potassium chloride, heparin, angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), and potassium-sparing diuretics; Although this condition occurs less frequently than hypokalemia, it can be much more dangerous.; Nerve conduction as well as muscle contractility can be affected; Skeletal muscle weakness and paralysis may occur
hyperkalemia
Serum magnesium >2.5 mEq/L; It usually occurs with renal failure when the kidneys fail to excrete magnesium or from excessive magnesium intake (use of magnesium-containing antacids or laxatives); Clinical manifestations include nausea, vomiting, weakness, flushing, lethargy, loss of DTRs, respiratory depression, coma, and cardiac arrest.
hypermanessemia
has a greater osmolarity than plasma (>295 mOsm/L); Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink.
hypertonic solution
Serum calcium <8.9 mg/dL, ionized calcium <4.5 mg/dL; Common causes related to a calcium deficit involve inadequate calcium intake, impaired calcium absorption, and excessive calcium loss; Manifestations include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures.
hypocalcemia
The major anion of the ECF; Serum chloride <96 mEq/L); A low level of chloride can result from severe vomiting and diarrhea, drainage of gastric fluid (GI tube), metabolic alkalosis, diuretic therapy, and burns; Manifestations include hyperexcitability of muscles, tetany, hyperactive DTRs, weakness, and muscle cramps.
hypochloremia
Serum magnesium <1.5 mEq/L; The most abundant intracellular cation after potassium; Magnesium loss may occur with nasogastric suction, diarrhea, withdrawal from alcohol, administration of tube feedings or parenteral nutrition, sepsis, or burns.; Manifestations - muscle weakness, tremors, tetany, seizures, heart block, change in mental status, hyperactive deep tendon reflexes (DTRs), and respiratory paralysis.
hypomagnesemia
Before nursing care is terminated, the patient and family should be able to
independently promote fluid, electrolyte, and acid-base balance.
The human body obtains water from several sources, including
ingested liquids, food, and as a byproduct of metabolism.
Electrolytes are substances that are capable of breaking into particles called?
ions
These charged particles are the basis of chemical interactions in the body necessary for metabolism and other functions.; The milliequivalent (mEq) is the unit of measure that describes the chemical activity of electrolytes. ; The total cations in the body are normally equal to the total anions, maintaining homeostasis (balanced state); When electrolytes are not in balance, the person is at risk for alterations in health.
ions
A solution that has about the same osmolarity as plasma (between 275 and 295 mOsm/L) .
isotonic solution
metabolism of carbohydrates and proteins, vital actions involving enzymes
magnesium
are cations, or positively charged ions
magnesium,, potassium, and calcium
The nurse evaluates the effectiveness of a care plan to promote fluid, electrolyte, and acid-base imbalances by checking whether the patient has
met the individualized patient goals specified in the plan.
is a proportionate deficit of biocarbinate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea
metabolic acidosis
Nursing assessment related to fluid, electrolyte, and acid-base balance should include a
nursing history, physical assessment, fluid intake and output, daily weights, and laboratory studies
The major method of transporting body fluids; Cell membranes are semi-permeable; Water moves from an are of lesser solute concentration and more water, to and area higher solute concentration and less water; The concentration of particles in a solution, or its pulling power, is referred to as the osmolarity of a solution
osmosis
Additional mechanisms responsible for regulating the shift of fluids and transporting materials to and from intracellular compartments are
osmosis, diffusion, active transport, and capillary filtration.
The unit of measure used to describe acid-base balance is pH; scale ranges from 1 to 14
pH
involved in important chemica reactions in the body, cell division, and hereditary traits
phosphate
chief regulator of cellular enzyme activity and water content
potassium
Major electrolytes in the ICF include
potassium, phosphorus, and magnesium
What can decreased arterial bloos pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low salt diet stimulate?
renin release
is when the carbon dioxide level is high and the pH is low
respiratory acidosis
When there is a single primary cause, these disturbances are known as?
respiratory acidosis or alkalosis and metabolic acidosis or alkalosis.
Fluid is lost from the body through
sensible and insensible losses.
controls and regulates volume of body fluids
sodium
Major electrolytes in the ECF include
sodium, chloride, calcium, and bicarbonate.
are substances that are dissolved in a solution.
solutes
liquids that hold a substance in solution
solvents
Body fluid is located in two fluid compartments called?
the intracellular fluid (ICF) or extracellular fluid (ECF).
What is the primary body fluid?
water
_____________in the body functions primarily to transport nutrients to cells and wastes from cells; transport hormones, enzymes, blood platelets, and red and white blood cells; facilitate cellular metabolism and proper cellular chemical functioning; act as a solvent for electrolytes and nonelectrolytes; help maintain normal body temperature; facilitate digestion and promote elimination; and act as a tissue lubricant.
water
what is the most important nutrient of life?
water