F&E, IV, Acid-Base, Elimination

in which order would the nurse treat the infiltration of a nonvesicant intravenous solution leaking into the extravascular tissue?

(1) Stop infusion and remove peripheral venous catheter; (2) apply a sterile dressing; (3) elevate the extremity; (4) use warm or cold compresses according to the solution infiltrated; (5) insert a new catheter in the opposite extremity; (6) obtain a study to determine the cause of the problem; (7) rate the infiltration using the INS infiltration Scale and document the procedure.

hyperkalemia S&S

>4.5. Tight and Contracted. ST elevation and peaked T waves, severe Vfib or cardiac standstill, hypotension, bradycardia. Diarrhea, hyperactive bowel sounds. Paresthesia, increased DTR, profound muscle weakness.

if hyperphosphatemia occurs,

HYPOcalcemia will occur simultaneously

an increase, NOT a decrease, in FV can lead to

Heart failure

T/F: if rehydration through IV can be avoided by administering oral fluids, then oral fluids are preferred.

T. Usually the least invasive means possible of rehydration is used for clients needing rehydration. Can be applied for "mild dehydration" (diagnosed based on BP and HR)

hypocalcemia S&S

Trousseau's signs, Chvostek's signs, diarrhea, circumonal tingling, weak bones, risk for bleeding, dysrhythmias.

whats an example of a plasma expander?

albumin

which assessment information best reflects an older adult client's f&e balance?

blood lab results (hemoglobin, hematocrit). Intake and output provide fluid balance data, not comprehensive F&E status.

which clinical indicators would the nurse assess after a client moves into the diuretic phase

dehydration, hypovolemia. excretion of fluids retained during the oliguric phase occurs and may reach 3-5L/daily; unless fluid replacement occurs, dehydration and hypovolemia are potential problems.

the nurse is caring for a client with preeclampsia being managed with magnesium sulfate infusion. which is the priority nursing assessment?

eliciting deep tendon reflexes. this is the priority because it is a very accurate assessment of therapeutic levels of magnesium sulfate.

profound/severe

end stage, severe

which ABNORMAL finding would the nurse monitor for during the oliguric phase of acute kidney injury

hyperkalemia... this is one of the main indicators for placing a client on hemodialysis when they are experiencing acute kidney injury.

infusion of high concentration of glucose will cause hypo/hypervolemia

hypervolemia as glucose is hypertonic

which symptom is indicative of the need for dialysis in the child with chronic kidney disease?

hypervolemia. Results when kidneys have failed and are no longer able to maintain homeostasis. Hypertension and cardiac overload is imminent. HYPERKALEMIA occurs with kidney failure as kidney is unable to filter phosphorus.

mannitol increases...

intravascular volume that must be excreted by the kidneys. Therefore, the client's urine output should be monitored hourly to determine the client's response to therapy. This can be monitored hourly, and is more frequent, accurate and efficient than a daily weight.

which clinical manifestation would the nurse expect to find in a client with hypokalemia?

low & slow! flat T waves, ST depression, ad prominent U wave. Decreased DTR, muscle cramping, flaccid paralysis. Decreased motility/peristalsis, hypoactive/absent bowel sounds, constipation, abdominal distention, paralyzed intestines.

hypertonic solutions

pull fluids from the cells, causing them to shrink and the extracellular (intravascular) space to expand.

electrolytes are specifically based on

serial assessments of serum electrolytes and arterial blood gases ABGS.

in what position should you place the client before changing the TPN tube?

supine position to decrease pressure in the vena cava, which helps prevent an air embolus when the catheter is disconnected.

hypercalcemia S&S

swollen and slow with moans, groans, and stones. Constipation, bone pain, stones, decreased deep tendon reflexes, muscle weakness, anorexia,

S&S of respiratory acidosis

vary. increase pulse, blood pressure, and respiratory rate. Confusion, disorientation, exhibit diminished level of consciousness. May cause HYPERkalemia as the hydrogen ion concentration overwhelms the compensatory mechanism. Complications/severe/profound: cerebral vasodilation will increase intracranial pressure, and cyanosis, and tachypnea will develop. COPD patients can develop acidosis over years as CO2 accumulates.

isotonic solutions act as a

volume expander to quickly replace volume losses and promote physiological stabilization.

which action would the nurse take before a client's scheduled hemodialysis treatment

weigh the client to establish a baseline for later comparison. we need to determine the net fluid loss from dialysis.

both hypertonic glucose and mannitol cause diuresis, the client receiving both of these should be monitored for...

excessive fluid loss AKA hypovolemic shock.

what does increased BUN cause in terms of symptoms?

fatigue and lethargy

which electrolytes does the opposite that calcium does?

phosphate

teaching the client how to perform peritoneal dialysis and the importance of preventing d=peritonitis

wear a mask during the procedure, clean the catheter exit every day, maintain meticulous aseptic technique, wash your hands before the exchange, store supplies in a clean and dry location

S&S of metabolic acidosis

headache, confusion, drowsiness, increased respiratory rate and N&V. Peripheral vasodilation and decreased cardiac output occur when the pH drops to less than 7. Additional findings include decreased blood pressure, cold/clammy skin, arrythmias, and shock.

S&S of respiratory alkalosis

lightheadedness and inability to concentrate due to cerebral artery vasoconstriction and decreased cerebral blood flow, numbness and tingling from decreased calcium ionization in the bloodstream, tinnitus, and sometimes loss of consciousness. Could include tachycardia and ventricular and atrial arrhythmias.

colloidal solution

mixture of fluid containing insoluble large particles, such as proteins. Exert oncotic pressure.

what increases in the oliguric phase when glomerular filtration is inadequate?

potassium. hyperkalemia occurs.

S&S of metabolic alkalosis

primarily manifested by symptoms R/T hypocalcemia due to free Ca+ ions decreasing by binding to negatively charged proteins in the bloodstream, HYPOKALEMIA as the nephrons increases H+ ion reabsorption.

crystalloid solution

water containing soluble mineral salts. Do not exert oncotic pressure.

factors that are identified as precipitating hyponatremia

wound drainage, diuretics (interfere with sodium reabsorption in the nephrons), GI suction (GI fluids are rich in sodium ions), inappropriate antidiuretic hormone secretion .

which calcium-rich food would the nurse suggest for clients who do not tolerate milk?

yogurt.. enzyme lactase breaks down milk sugar