Fluid and Electrolytes (9:35am-11:56am)
A client is scheduled for an arterial blood gas specimen to be drawn, and the nurse assists with performing Allen's test on the client. Arrange the steps for performing Allen's test in order of priority.
1. Explain procedure 2. Apply pressure over the Ulnar and radial arteries 3. Ask the client to open and close the hand repeatedly 4. Assess the color of the extremity distal to the pressure point. 5. Release pressure from the ulnar artery. 6. Document the findings.
A nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period?
1oz = 30mL Add all the fluids that the patient contains and multiply to 30mL =2,520ml =84 oz
RISK FOR FLUID VOLUME EXCESS
A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess.
A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.
Answer: - Diabetic mellitus client - Malnourished client - Renal failure client Rationale: Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body.
A nurse is reviewing the health care records of assigned clients. Which client is at risk for excess fluid volume?
Answer:The client with renal failure Rationale: The causes of excess fluid volume include decreased kidney function, heart failure, cirrhosis, the use of hypotonic fluids to replace isotonic fluid losses, and the excessive ingestion of table salt.
Respiratory Acidosis
Decrease ph---Below 7.35 Increased HCO3---Above 27 mEq/L Decrease Pao2 ---75-100 Increase Paco2-- 35 to 45 mm Hg Increase Potassium---above 5.0 HC03: Bicarbonate Ph: Arterial blood pH Pao2: Partial Pressure of oxygen in arterial blood Paco2: Partial pressure of carbon dioxide in arterial blood
Which clients are at high risk for metabolic acidosis
Diabetes clients Renal failure clients Malnourishment clients Rationale: Diabetes mellitus, renal failure, and malnutrition lead to metabolic acidosis by increasing acids in the body.
APNEA
In apnea, respirations cease for several seconds.
BRADYPNEA
In bradypnea, respirations are regular but abnormally slow
HYPERPNEA
In hyperpnea, respirations are labored and increased in depth and rate.
KUSSMAULS RESPIRATIONS
Kussmaul's respirations are abnormally deep, regular, and increased in rate
Food with CALCIUM
Milk, spinach, and collard greens are calcium-containing foods
Metabolic Acidosis
Ph: Decrease HCO3: Decrease PO2: Normal PCO2: Normal or Decrease K+: Increase
Respiratory Alkalosis
Ph: Increase HCO3: Decrease PO2: Normal PCO2: Decrease K+: Decrease
Metabolic Alkalosis
Ph: Increase HCO3: Increase PO2: Normal PCO2: Normal or Increase K+: Decrease
A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by doing which of the following?
Pulling up and releasing the skin on the sternal area Rationale: Skin turgor is the skin's elasticity. To assess turgor, a fold of skin is grasped on the back of the forearm or sternal area with the fingertips and released. Normally the skin lifts easily and snaps back to its resting position. The skin stays pinched when turgor is poor.
A nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, PCO2 of 52 mm Hg, and HCO of 22 mEq/L. The nurse interprets these results as indicating:
Respiratory acidosis Normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO2. In this situation, the pH is low and the PCO2 is increased.
The nurse is told that the blood gas results indicate a pH of 7.50 and a Pco2 of 32 mm Hg. The nurse determines that these results indicate:
Respiratory alkalosis--- Ph is elevated PCO2 is decreased
Sensible Losses
Sensible losses are those that the person is aware of, such as those that occur through wound drainage, GI tract losses, and urination
Risk for Hypokalemia
The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.
A nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs Allen's test first. The nurse understands that this is being done to determine the adequacy of the:
Ulnar circulation Rationale: Allen's test is done to test the adequacy of the ulnar circulation before drawing an ABG.
A nursing student is assigned to care for a child that has been experiencing vomiting and diarrhea. The health care provider documents a diagnosis of gastroenteritis and isotonic dehydration. The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating that it occurs when: ISOTONIC DEHYDRATION:
Answer: "Water and electrolytes are lost in approximately the same proportion as they exist in the body." Rationale: Isotonic dehydration occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body. In this type of dehydration, the serum sodium levels remain normal (135 to 145 mEq/L).
A nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the albumin level report indicates which critical level? NORMAL serum albumin level in the adult is 3.4 to 5 g/dL.
Answer: 2.8 g/dL Rationale: The serum albumin level is a critical indicator of the need for PN. The client whose albumin level is 2.8 g/dL is at severe risk for malnutrition. The normal serum albumin level in the adult is 3.4 to 5 g/dL.
A nurse is assisting in the care of a client who is at risk for hyponatremia. The nurse would monitor this client for which of the following manifestations of this electrolyte imbalance?
Answer: Abdominal cramping Rationale: Signs of hyponatremia include rapid, thready pulse; postural blood pressure changes; weakness; abdominal cramping; poor skin turgor; muscle twitching and seizures; mental confusion; and apprehension.
A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that the completion time for the bag is:
Answer: 21:30 Rationale: At a rate of 80 mL per hour, the 1000-mL bag will be finished infusing in 12½ hours. This brings the end time to 21:30, using military time.
A nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which of the following additional laboratory values would the nurse expect to note?
Answer: A potassium level of 3.2 mEq/L Rationale: Clinical manifestations of respiratory alkalosis include tachypnea, mental status changes, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia
A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which of the following medications that would be prescribed to treat this acid-base disorder?
Answer: Acetazolamide (Diamox) Rationale: Acetazolamide is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase.
The nurse reviews the client's serum phosphorus level and notes that the level is 2.0 mg/dL. The nurse understands that which condition caused this serum phosphorus level? Normal serum phosphorus level is 2.7 to 4.5 mg/dL
Answer: Alcoholism Rationale: The client in this question is experiencing hypophosphatemia. Causative factors relate to decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism.
A nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for injury?
Answer: Applying pressure to the site Rationale: Pressure should be applied to the site following an ABG draw. The pressure in the artery is higher than in the veins. It is therefore necessary to apply pressure to the punctured artery to control bleeding.
A nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse tells the client that which food item contains the least amount of calcium?
Answer: Butter Rationale: Butter comes from milk fat and does not contain significant amounts of calcium.
A client is at risk for developing hypocalcemia. The nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted?
Answer: Positive Trousseau's sign Rationale: Signs of hypocalcemia include paresthesias, hyperactive reflexes, and a positive Trousseau's or Chvostek's sign.
A client has a serum sodium level of 129 mEq/L because of hypervolemia. The nurse consults with the health care provider to determine whether which measure should be instituted?
Answer: Restricting fluid intake Rationale: Hyponatremia is defined as a serum sodium level of less than 135 mEq/L. When it is caused by hypervolemia, it may be treated with fluid restriction.
A nurse is caring for a client who has been taking diuretics on a long-term basis. A fluid volume deficit is suspected. Which finding would be noted in the client with this condition?
Answer: Increased specific gravity of the urine Rationale: Findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness.
A nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. On the basis of this laboratory value, the nurse takes which action? NORMAL CALCIUM- 8.6-10.2 mg/dL
Answer: Informs the registered nurse of the laboratory value Rationale: The client is experiencing hypercalcemia, and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia
A nurse is assisting in the care of a group of clients on the nursing unit. The nurse determines that a client with which of the following diagnoses is the one who has the least amount of risk for developing third-spacing of body fluid?
Answer: Ischemic stroke Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third-spacing include the pleural and peritoneal cavities and the pericardial sac. Clients at high risk for third-spacing include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition.
A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse most likely observe?
Answer: KUSSMAULS---Respirations that are abnormally deep, regular, and increased in rate
A nurse assists in developing a plan of care for the child with meningitis. What is the priority nursing diagnosis for this child?
Answer: Risk for ineffective cerebral tissue perfusion Rationale: Risk for ineffective cerebral tissue perfusion is the priority problem for the child with meningitis. Pain related to meningeal irritation may also be an appropriate problem, but is not the priority
The nurse is caring for a client with renal failure. The laboratory results reveal a magnesium level of 3.6 mg/dL. Which of the following signs would the nurse expect to note in the client, based on this magnesium level? Normal Magnesium: 1.6 to 2.6 mg/dL
Answer: Loss of deep tendon reflexes Rationale: A client with a magnesium level of 3.6 mg/dL is experiencing hypermagnesemia. Loss of deep tendon reflexes is characteristic of this condition.
A nurse is monitoring the fluid balance of a client with human immunodeficiency disease (HIV). Because loss of subcutaneous adipose tissue and muscle atrophy occur in such clients, the nurse understands that which of the following will provide a reliable indicator of fluid balance?
Answer: Decreased urine output and hypotension Rationale: With the loss of muscle mass and adipose tissue, the overlying skin loses its support. The usual elasticity of skin becomes a less reliable indicator of body fluid status. Vomiting and diarrhea may cause weight loss and electrolyte imbalances, but the amount that is vomited does not precisely correlate with the amount of fluid remaining in the body because systems such as the kidney can help reestablish equilibrium.
Which of the following arterial blood gas (ABG) results should the nurse anticipate in the client with profuse vomiting for 2 days?
Answer: pH 7.49; Pco2 45; HCO 30 rationale: Vomiting results in a loss of hydrogen ions from the gastrointestinal tract, which leads to an increase in serum bicarbonate. Metabolic alkalosis occurs with an excess in serum bicarbonate. In metabolic alkalosis the pH rises as does the bicarbonate.
A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
Answer: Metabolic alkalosis Rationale: The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid;
The nurse is told in a report that the client has hypocalcemia and a positive Chvostek's sign. What data would the nurse expect to note during the data collection?
Tetany Diarrhea Possible Seizure Activity A positive Trousseau's sign Rationale: A positive Chvostek's sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, a positive Trousseau's sign, diarrhea, seizures, hyperactive bowel sounds, and a prolonged QT interval.
A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid doing which of the following?
Answer: Encouraging the client to breathe slowly and shallowly Rationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels because of insufficient ventilation.
The nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for a potassium deficit? RISK FOR POTASSIUM DEFICIT
Answer: RISK FOR POTASSIUM DEFICIT----The client receiving nasogastric suction Rationale: (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia.
Which of the following electrocardiogram changes should the nurse note on the cardiac monitor with a client whose potassium (K+) level is 3.2 mEq/L?
Answer: U waves Rationale: A serum potassium level less than 3.5 mEq/L is indicative of hypokalemia. Potassium deficit is the most common electrolyte imbalance and is potentially life threatening. Cardiac changes with hypokalemia may include peaked P waves, flattened T waves, depressed ST segment, and the presence of U waves.
A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, PCO2 of 34 mm Hg, PO2 of 86 mm Hg, and HCO of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?
Answer: Metabolic acidosis Rationale: Acidosis is defined as a pH of less than 7.35, and alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the PCO2 is greater than 45, and respiratory alkalosis is present when the PCO2 is less than 35. Metabolic acidosis is present when the pH is less than 7.35 and the HCOis less than 22 mEq/L, whereas metabolic alkalosis is present when the pH is greater than 7.45 and the HCO is greater than 27 mEq/L. This client's ABGs are consistent with metabolic acidosis.
Sign of HYPOCALCEMIA
Twitching Positive Trousseau's sign Hyperactive bowel sounds
A nurse is caring for a client with cirrhosis. The nurse notes that the client is dyspneic and crackles are heard on auscultation of the lungs. What additional signs would the nurse expect to note in this client if a fluid volume excess is present? FLUID VOLUME EXCESS
Answer: FLUID VOLUME EXCESS----An increase in blood pressure Rationale: Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.
An older adult client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which of the following manifestations that correlates with this client's fluid imbalance?
Answer: Flat neck veins Rationale: A client with dehydration has a fluid volume deficit, which can be reflected by flat neck veins.
A nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which of the following signs would be an indication of this diagnosis?
Answer: Generalized muscle weakness Rationale: Generalized muscle weakness is seen in clients with hypercalcemia.
A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse should monitor this client for signs of which of the following electrolyte disorders that could accompany the acid-base imbalance?
Answer: Hypokalemia Rationale: Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia.
A nurse is assisting in the care of a group of clients on the clinical nursing unit. The nurse monitors the fluid balance of a client who has which of the following diagnoses and is most at risk for fluid volume deficit?
Answer: Ileostomy Rationale: The client with an ileostomy is at risk for fluid volume deficit due to increased gastrointestinal tract losses.
A nurse is caring for a client whose magnesium level is 4 mg/dL, and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which sign or symptom is no longer present? Normal magnesium level is 1.6 to 2.6 mg/dL
Answer: Loss of deep tendon reflexes Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 4 mg/dL is experiencing hypermagnesemia. Signs include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, tachycardia and hypotension, and loss of consciousness. Tetany, muscular excitability, and twitches are seen in a client with hypomagnesemia.
A client with diabetes mellitus has a blood glucose on admission of 596 mg/dL. The nurse anticipates that this client would be experiencing which of the following types of acid-base imbalance?
Answer: Metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises while the cells of the body use all available glucose and then break down glycogen and fat for fuel.
A licensed practical nurse (LPN) is assisting in the care of a client who overdosed on aspirin 24 hours ago. The LPN would report to the registered nurse (RN) which of the following findings associated with an anticipated acid-base disturbance?
Answer: Drowsiness, headache, and tachypnea Rationale: The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea.
A nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned client is at risk for excess fluid volume?
Answer: The client with renal failure Rationale: The client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid
A nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The client is being treated with an intravenous hypertonic saline. The nurse determines that the treatment measures are effective when the laboratory results reveal a serum sodium level of:
Answer: 140 mEq/L Rationale: Hyponatremia is defined as a serum sodium level of less than 135 mEq/L. When it is caused by hypervolemia, it may be treated with fluid restriction. The low serum sodium value is a result of hemodilution. Intravenous hypertonic saline (3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L. The normal serum sodium level is 135 to 145 mEq/L
A nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume in which of the following clients who is at risk for this fluid imbalance?
Answer: A client with an ileostomy Rationale: The client with an ileostomy is at risk for deficient fluid volume because of increased gastrointestinal tract losses. Other causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, or the presence of an ileostomy or colostomy. Clients who have heart failure, renal failure, or major trauma are at risk for excess fluid volume.
A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists to implement which measure as the effective means to treat the problem?
Answer: Administer prescribed antibiotics. Rationale: The most effective way to treat an acid-base disorder is to treat the underlying disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base disorder.
A nurse is assigned to care for a group of clients on the clinical nursing unit. The nurse determines that the client who is least likely to develop third spacing of fluids is the one with a diagnosis of:
Answer: Hypertension Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as "third space fluid." This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavities and the pericardial sac. Risk factors include the older client, and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, and gastrointestinal malabsorption and malnutrition.
A nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse should then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?
Answer: Hypokalemia Rationale Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and seizures.
A 3-year-old child is hospitalized because of persistent vomiting. Which of the following conditions would the nurse expect to occur in this child?
Answer: Metabolic alkalosis Rationale: Vomiting will cause the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea may not accompany vomiting.
A nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which of the following would be initially noted in the client if hyperkalemia is present?
Answer: Muscle weakness Rationale: Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness not muscle pain.
A nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse note on the cardiac monitor as a result of this laboratory value?
Answer: Narrow, peaked T waves Rationale: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; narrow, peaked T waves; and a depressed ST segment.
A nurse is assisting to admit a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which of the following acid-base imbalances?
Answer: Respiratory acidosis Rationale: Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration.
A nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse monitors the client for which acid-base imbalance that most likely occurs in clients with this condition?
Answer: Respiratory acidosis Rationale: Respiratory acidosis most often occurs as a result of primary defects in the function of the lungs or changes in normal respiratory patterns from secondary problems.
A nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a PCO2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which of the following additional laboratory values would the nurse expect to note in this client?
Answer: Potassium 5.4 mEq/L Rationale: Serum potassium levels are often high in acidosis as the body attempts to maintain electroneutrality during buffering.
An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse would do which of the following to help the client experiencing this acid-base disorder?
Answer: Provide emotional support and reassurance. Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication, if it is prescribed.
A nurse is caring for a client with a nasogastric tube who has prescriptions to have the tube irrigated once every 8 hours. The nurse ensures that which of the following solutions is placed in the client's room to be used for the irrigation when the client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L?
Answer: Normal saline Rationale: A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, normal (isotonic) saline should be used rather than sterile water (hypotonic) for gastrointestinal irrigations. It is not ordinary clinical practice to irrigate with 5% dextrose solution.
A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, the initial nursing action would be to:
Answer: Obtain orthostatic vital signs. Rationale: The initial nursing action is to determine the client's level of dehydration. Orthostatic vital signs (blood pressures and pulses, lying, sitting, standing) are actions to determine the probability of fluid losses. A drop of more than 10 to 20 mm Hg and an increased pulse rate of 10 to 20 beats per minute probably indicate a significant intravascular fluid volume deficit.
A nurse is assisting in the care of a client who had an ileostomy created a few days ago. Owing to the normally high output of drainage from this type of ostomy, the nurse monitors the client for signs of:
Answer: Metabolic acidosis Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed in conditions such as diarrhea or creation of an ileostomy.
A nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?
Answer: Metabolic alkalosis Rationale: Excessive use of oral antacids containing sodium or calcium bicarbonate can cause metabolic alkalosis.
A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that can occur in a client with an ileostomy?
Answer: Metabolic acidosis Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions such as diarrhea or creation of ileostomy.
A nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?
Answer: Metabolic acidosis Rationale: Intestinal secretions high in bicarbonate may be lost through enteric drainage tubes, an ileostomy, or diarrhea.
A nurse is caring for a client who is nervous and is hyperventilating. The nurse would monitor the client for signs of which of the following acid-base imbalances?
Answer: Respiratory alkalosis Rationale: A client who hyperventilates blows off excessive carbon dioxide. This would have the effect of inducing alkalosis. Because a respiratory problem is triggering the alteration, it is called respiratory alkalosis.
A health care provider (HCP) is discussing the fluid balance of a postoperative client. The HCP states the client's insensible fluid loss is approximately 600 mL daily. The nurse interprets that the HCP is referring to fluid loss that is occurring through the:
Answer: Skin and lungs Rationale: insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. They occur on a daily basis without the client's awareness.
A nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition? NORMAL POTASSIUM 3.5 to 5.0 mEq/L
Answer: Traumatic Burn Rationale: A serum potassium level that exceeds 5.1 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia
A client enters the emergency room confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply.
- Monitor intake and output. - Monitor the vital signs. - Monitor the electrolyte levels. - Increase water intake orally. - Provide a sodium-reduced diet Rationale: Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L. Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia.
A client has the following laboratory values: a pH of 7.55, an HCO level of 22 mm Hg, and a Pco2 of 30 mm Hg. What should the nurse do? Normal pH 7.35 to 7.45 Normal HCO 22 to 27 mEq/L Normal Pco2 35 to 45 mm Hg PO2 80 to 100 mm Hg
Answer: Encourage the client to slow down breathing. Rationale: The client is in respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed.
A nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L. The nurse would determine that this is an expected finding if the client had which of the following health problems?
Answer: Severe burn injury Rationale: A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia. This electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. The client with Cushing's syndrome, ulcerative colitis, or diarrhea is at risk for hypokalemia.
A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at the lowest risk for the development of third-spacing?
Answer: THIRD SPACING------The client with diabetes mellitus Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells.
A nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse understands that this sodium level would be noted in a client with which condition? Normal Sodium--135 to 145 mEq/L
Answer: The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Rationale: Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can result secondary to SIADH. The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.
A nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through:
Answer: The skin Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.
The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which finding did the nurse note?
Answer: The skin when pinched immediately fell back to normal when released. Rationale: Turgor (degree of elasticity) is checked by gently pinching up the skin over the abdomen, forearm, sternum, forehead, or thigh. In a person with normal fluid balance, the skin when pinched will immediately fall back to normal when released. If a fluid deficit is present, the skin may remain elevated or tented for several seconds after the pinch.
A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. A nurse assists with performing Allen's test before drawing the blood to determine the adequacy of the:
Answer: Ulnar circulation Rationale: Before performing a radial puncture to obtain an arterial specimen for ABGs, Allen's test should be performed to determine adequate ulnar circulation.
A nurse is planning to reinforce dietary teaching about foods that are low in potassium to a client receiving a potassium-sparing diuretic. The nurse would be sure to include which of the following on a list of foods that have low potassium content?
Answer: White bread Rationale: A slice of white bread provides 27 mg of potassium. Raw spinach (3½ ounces) provides 470 mg of potassium. One avocado provides 1097 mg of potassium, and 4 ounces of pork provides 525 mg of potassium.
The registered nurse reviews the results of the arterial blood gases with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to note which of the following on the laboratory result form?
Answer: pH 7.25, Pco2 50 mm Hg Rationale: In respiratory acidosis, the pH is down and the Pco2 is up
A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder?
Answer: Decreased respiratory depth and rate and dysrhythmias Rationale: The client with metabolic alkalosis is likely to exhibit a decrease in respiratory rate and depth, nausea, vomiting, diarrhea, restlessness, numbness and tingling in the extremities, twitching in the extremities, hypokalemia, hypocalcemia, and dysrhythmias.
A nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.3 mg/dL. The appropriate nursing intervention is to:
Answer: Monitor the client for dysrhythmias. Rationale: Hypomagnesemia is defined as a plasma magnesium level less than 1.6 mg/dL. The client should be monitored for dysrhythmias because the client is predisposed particularly to ventricular dysrhythmias. The client also should consume foods high in magnesium.
A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit?
Answer: The client with a colostomy Rationale: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy.
A client who has fallen from a roof and fractured his ribs has arterial blood gas results of: pH 7.48, PaCO2 32 mm Hg, PaO2 89 mm Hg, and HCO 22 mEq/L. The nurse interprets that the client's blood gases indicate which of the following?
Answer: Respiratory alkalosis Rationale: The client has respiratory alkalosis. Normal ranges are pH 7.35 to 7.45, PaCO2 35 to 45, and bicarbonate level 22 to 26 mEq/L. With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be elevated in respiratory acidosis.
