Fluid and Electrolytes I
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 water (D5W) b. 0.9% NaCl (normal saline) c. Lactated Ringer's solution d. 0.33% NaCl (¹∕³-strength normal saline) e. 0.45% NaCl (½-strength normal saline) f. 10% dextrose in water (D10W)
A, D, E 5% dextrose in water (D5W), 0.33% NaCl (¹∕³-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 10% dextrose in water (D10W) is used in peripheral parenteral nutrition (PPN).
A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply. a. respiratory muscle weakness b. confusion c. ventricular dysrhythmia d. constipation e. abdominal distention
A,B,C With hypophosphatemia, findings include neuromuscular dysfunction; weakness, especially respiratory muscles; fatigue; myocardial depression; ventricular dysrhythmias; rhabdomyolysis; confusion, coma; decreased oxygen delivery to tissues; renal loss of bicarbonate, calcium, magnesium, and glucose; bone changes (osteomalacia); and endocrine changes (insulin resistance). Abdominal distention and constipation are more commonly associated with hypokalemia.
A nurse is providing care to a client with an ECF volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply. a. orthostatic hypotension b. dry mucous membranes c. decreased urine output d. slow-filling peripheral veins e. poor skin turgor
A,C,D The signs and symptoms of an ECF volume deficit reflect decreases in fluid volume in the vascular and interstitial spaces. The signs and symptoms of a decrease in vascular volume include orthostatic or postural changes in pulse rate and blood pressure (i.e., an increase in pulse rate and decrease in blood pressure when the person moves from a lying to a standing position); weak, rapid pulse; decreased urine output; and slow-filling peripheral veins. The signs and symptoms of decreased interstitial volume include dry mucous membranes and poor skin turgor.
The nurse is teaching proper nutrition to a client who has been prescribed high-ceiling diuretic therapy. Which client response indicates a need for further teaching? a. "I should eat more eggs and cereals to maintain a high potassium intake." b. "Eating meat will help with my potassium needs." c. "I should eat fish a few times a week." d. "I should have fruits such as oranges, kiwi, and bananas every day."
A. "I should eat more eggs and cereals to maintain a high potassium intake." Breads, eggs, and cereal grains contain the least amount of natural potassium. Meats, fish, fruits, and some vegetables are highest in potassium. Diuretics that increase the kidney excretion of potassium can cause hypokalemia. The client should be encouraged to eat foods high in potassium when taking high-ceiling diuretic agents to help compensate for potassium loss.
A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. He tells a nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The nurse starts the client's IV and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer this medication? a. Added to an IV, not to exceed 20 mEq/hr b. Added to an IV, not to exceed 30 mEq/hr c. Rapid IV push, a 25-mEq dose d Slow IV push, a 30-mEq dose
A. Added to an IV, not to exceed 20 mEq/hr The maximum recommended infusion rate of potassium is 5-10 mEq/hr. This rate is never to exceed 20 mEq/hr under any circumstances. Potassium should never be administered via IV push.
Laboratory results for a client with a large draining abdominal wound show a serum sodium decrease from 138 mEq/L to 131 mEq/L. What is the nurse's first action? a. Assess the client's respiratory status. b. Establish intravenous access. c. Notify the provider of laboratory results. d. Assess for orthostatic hypotension.
A. Assess the client's respiratory status. Hyponatremia may present with neuromuscular changes including muscle weakness of the legs, arms, and respiratory muscles. The nurse should assess the respiratory effectiveness of a client with hyponatremia as a priority. Obtaining assessment data is important when calling the provider in addition to reporting the laboratory result. Establishing IV access and assessing for orthostatic hypotension are important, but are lower-priority interventions.
The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? a. Calcium level of 9.5 mg/dL b. Magnesium level of 4.1 mEq/L c. Potassium level of 6.0 mEq/L d. Sodium level of 120 mEq/L
A. Calcium level of 9.5 mg/dL Because a calcium level of 9.5 mg/dL is within normal limits, it is appropriate to assign this client to an LPN/LVN. A magnesium level of 4.1 mEq/L, potassium level of 6.0 mEq/L, and a sodium level of 120 mEq/L are abnormalities in electrolytes that can cause serious complications and will require assessments and/or interventions by the RN.
The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? a. Client behavior that changes from anxious and restless to lethargic and confused b. Deep furrows on the surface of the tongue c. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched d. Urine output of 950 mL for the past 24 hours
A. Client behavior that changes from anxious and restless to lethargic and confused The client's change in level of consciousness from anxious and restless to lethargic and confused suggests poor cerebral blood flow, or shrinkage or swelling of brain cells caused by fluid shifts within the brain cells. These changes indicate a need for immediate intervention to prevent further damage to cerebral function. Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.
Which situation can cause a client to experience "insensible water loss"? Select all that apply. a. Diarrhea b. Dry, hot weather c. Fever d. Increased respiratory rate e. Nausea f. Mechanical ventilation
A. Diarrhea B. Dry, hot weather C. Fever D. Increased respiratory rate F. Mechanical ventilation Insensible water loss occurs through the intestinal tract as diarrhea. It can be caused and/or influenced by dry, hot weather. Insensible water loss occurs through the skin, lungs (increased rate of respirations), and intestinal tract. It is increased in clients who are mechanically ventilated, and it is increased by the presence of fever. Nausea with no accompanying vomiting would not cause insensible water loss.
How is isotonic dehydration defined? a. Fluids and electrolytes are lost from the body in equal amounts. b. Fluids are lost from the body in greater quantities than electrolytes. c. Electrolytes are lost from the body in greater quantities than fluids. d. Fluids and electrolytes are lost from the body, but only water is used to replace losses.
A. Fluids and electrolytes are lost from the body in equal amounts. Isotonic dehydration is when fluids and electrolytes are lost in equal quantities. Hypertonic dehydration occurs when fluids are lost in greater quantities than electrolytes. Hypotonic dehydration occurs when electrolytes are lost in greater quantities than fluids, or when fluid and electrolyte losses are replaced by water only.
A client's electrocardiogram demonstrates a heart rate of 52 beats/min, prolonged PR interval with widened QRS complex, and the client is also hypotensive. The nurse reviews the morning labs for which conditions? a. Hyperkalemia, hypercalcemia, hypermagnesemia b. Hypokalemia, hypocalcemia, hypermagnesemia c. Hypocalcemia, hyperkalemia, hypernatremia d. Hypernatremia, hypercalcemia, hypophosphatemia
A. Hyperkalemia, hypercalcemia, hypermagnesemia Cardiovascular changes are consistent with elevated potassium, calcium, and magnesium. These signs and symptoms may progress to life-threatening cardiac emergency. Although hypocalcemia can interfere with cardiac contractility, hypokalemia and hypophosphatemia do not.
A client is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect? a. Hypernatremia b. Hypomagnesemia c. Hypercalcemia d. Hyperphosphatemia
A. Hypernatremia These symptoms are indicative of hypernatremia. Clinical manifestations of hypomagnesemia are seen in the neuromuscular, central nervous, and intestinal systems. Hypercalcemia manifests with an altered level of consciousness that can range from confusion and lethargy to coma, and severe hypercalcemia depresses electrical conduction, slowing heart rate. Hyperphosphatemia causes few direct problems with body function (although hypocalcemia is usually also present).
A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Laboratory results include a potassium level of 7.0 mEq/L. Which medication does the nurse anticipate administering? a. Insulin (regular insulin) and dextrose (D20W) b. Loperamide (Imodium) c. Sodium polystyrene sulfonate (Kayexalate) d. Supplemental potassium
A. Insulin (regular insulin) and dextrose (D20W) If potassium levels are high, a combination of 20 units of regular insulin in 100 mL of 20% dextrose may be prescribed to promote movement of potassium from the blood into the intracellular fluid (ICF). Imodium is used in the treatment of diarrhea. Kayexalate is used for hyperkalemia, but not when the potassium level is this high (7.0). Additional potassium would make the client's condition more critical.
Which drug therapies might be used to manage symptoms of hypocalcemia? Select all that apply. a. Magnesium sulfate b. Calcium chloride c. Potassium chloride (K-Dur) d. Vitamin D (Calcitrol) e. Zinc sulfate (Zinc 220) f. Vitamin E (alpha tocopherol)
A. Magnesium sulfate B. Calcium chloride D. Vitamin D (Calcitrol) Magnesium sulfate may be used to manage neuromuscular symptoms of hypocalcemia. Calcium supplements are given to restore serum calcium levels. Vitamin D enhances the absorption of oral calcium. Potassium, zinc, and vitamin E are not indicated for the management of hypocalcemia.
A client has had a total urine output of 200 mL in the past 24 hours. Which priority action does the nurse take? a. Notify the primary health care provider. b. Encourage the client to drink more fluids. c. Take no action because this is a normal urinary output. d. Insert an indwelling urinary catheter.
A. Notify the primary health care provider. The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. With a urine output of 200 mL in 24 hours, a toxic buildup of nitrogen and lethal electrolyte imbalances can occur. The primary health care provider should be notified because additional tests or orders might be necessary. Encouraging the client to drink more fluids may be necessary once the underlying cause of the decreased urine output (oliguria) is determined. Inserting an indwelling urinary catheter may be indicated, but not before speaking with the provider.
A nurse is preparing a presentation for a group of older adults at a local senior center about the importance of fluid intake. As part of the presentation, the nurse plans to discuss how the intake and output of fluids is typically balanced each day. When describing the normal daily output of fluids, which component would the nurse identify as accounting for the smallest amount of fluid output? a. Perspiration b. Feces c. Exhaled air d. Urine
A. Perspiration Normal urine output for 24 hours is approximately 1,500 mL if intake is normal. Loss of fluid through the skin as perspiration accounts for an average daily loss of 100 to 200 mL of fluid. In addition to perspiration, insensible fluid loss through the skin amounts to about 300 to 400 mL per day. Loss of fluid through the gastrointestinal system in the form of feces is usually minimal, approximately 200 mL per day. Loss of water through respiration is approximately 300 mL per day.
Which nursing action is recommended when providing care to a client with hypokalemia? a. Question the continued administration of bumetanide (Bumex). b. Obtain the prescribed vial of IV potassium chloride from the pharmacy and dilute before administration. c. Establish a peripheral IV, preferably in the hand, for administering IV potassium chloride. d. Administer prescribed oral potassium chloride (K-Dur) before a meal or snack.
A. Question the continued administration of bumetanide (Bumex). Bumetanide is a loop diuretic, which contributes to potassium loss and should be questioned. The Joint Commission has mandated that all concentrated electrolytes be mixed by a pharmacist and that vials of KCl should not be available in client care areas. A large vein with high blood flow should be accessed to avoid phlebitis; it is recommended that the hand be avoided. Oral potassium supplements should be given with or following a snack or meal to avoid nausea.
Which intervention does the nurse include in caring for a client with generalized edema who is receiving a loop diuretic? a. Turning the client every 2 hours. b. Encouraging oral fluids. c. Restricting dietary potassium. d. Applying antiembolism stockings.
A. Turning the client every 2 hours. The client with generalized edema/fluid overload is at risk for developing skin breakdown, especially at pressure points over bony prominences. Changing position frequently reduces this risk. Fluids are more likely to be restricted with fluid overload, not encouraged. Loop diuretics cause potassium loss so dietary potassium is encouraged, not restricted. Antiembolism hose have no role in generalized edema from fluid overload.
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? a. calcium and phosphorus b. potassium and sodium c. chloride and magnesium d. potassium and chloride
A. calcium and phosphorus The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances.
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism would the nurse most likely address? a. increased hydrostatic pressure b. decreased colloid oncotic pressure c .increased capillary permeability d. blockage of the lymph nodes
A. increased hydrostatic pressure The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.
Which question is most important for the nurse to ask the client who has a serum potassium level of 2.9 mEq/L? a. "Do you use sugar substitutes?" b. "Do you use diuretics or laxatives?" c. "Have you had any muscle twitches or cramps, especially at night?" d. "Have you or any member of your family ever been diagnosed with lung disease?"
ANS: B The serum potassium level is low, and the client has hypokalemia. Misuse or overuse of diuretics, especially high-ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia among older adults and clients with eating disorders. Sugar substitutes do not change serum potassium levels. Muscle cramps and twitching may occur with hyperkalemia and hypocalcemia but not with hypokalemia. Lung disease is not associated with hypokalemia.
Which assessment finding indicates to the nurse that fluid resuscitation therapy for the client with isotonic dehydration is effective? a. Respiratory rate has changed from 16 to 18 breaths/min b. Urine specific gravity has increased from 1.040 to 1.050 c. Neck veins are flat when the client moves to a sitting position d. Pulse pressure has changed from 22 mm Hg to 32 mm Hg
ANS: D Isotonic dehydration manifests as hypovolemia and shock. The increasing pulse pressure (difference between the diastolic and systolic blood pressures) is an indication that the fluid volume deficit is being corrected.
Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? a. The client has twitching muscle contractions in the lower extremities b. The client's skin is cool and clammy c. The urine specific gravity is increased d. The hematocrit is 52%
ANS: D The serum sodium level is elevated, indicating hypernatremia. The elevation could be from an actual increase in sodium or from a loss of fluids only. A relative hypernatremia can occur as a result of dehydration (excessive fluid loss) without sodium loss. Such dehydration is usually accompanied by hemoconcentration. The higher than normal hematocrit suggests hemoconcentration.
The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L. Which finding would the nurse expect to assess? Select all that apply. a. Polydipsia b. Cardiac dysrhythmia c. Polyuria d. Muscle weakness e. Diarrhea
B,E The client's potassium level suggests hyperkalemia, which is manifested by anxiety; irritability; gastrointestinal hyperactivity (diarrhea and intestinal cramping); tall, peaked T waves on electrocardiogram; and cardiac dysrhythmias. Muscle weakness, polyuria and polydipsia would be noted with hypokalemia.
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 been taking antacids almost every 2 hours over the past several days." c. "I've had a fever for the past 3 days that just doesn't seem to go away." d. "I've had a GI virus for the past 3 days with severe diarrhea."
B. "I've been taking antacids almost every 2 hours over the past several days." 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.
When administering 20 mEq potassium chloride intravenously (IV), which is the priority intervention? a. Monitor for pain or burning at the IV infusion site. b. Administer at a rate of 10 mEq/hr. c. Monitor respiratory rate and depth. d. Place the client on a heart monitor during administration.
B. Administer at a rate of 10 mEq/hr. The maximum recommended infusion rate is 5-10 mEq/hr to avoid potentially lethal cardiac dysrhythmias. Monitoring for pain at the IV infusion site, assessing respiratory rate and depth, and placing the client on a heart monitor are all appropriate options, but because a rapid rate of administration could have lethal effects, it has the greatest priority.
What history and assessment findings may be associated with hypocalcemia in a 22-year-old man? Select all that apply. a. Decreased deep tendon reflexes without paresthesia b. Awakening at night with muscle spasms in the calf c. Recent blunt trauma to the throat during a football game d. Absent bowel sounds e. Tingling around the mouth
B. Awakening at night with muscle spasms in the calf C. Recent blunt trauma to the throat during a football game E. Tingling around the mouth A history of anterior neck injury may be associated with hypocalcemia. Symptoms of hyporcalcemia include "charley horses" in the calf during rest or sleep, and tingling in the lips. Hypocalcemia does not affect bowel sounds. Decreased deep tendon reflexes without paresthesia is a neuromuscular change in hypercalcemia.
A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer's solution IV for rehydration. What clinical manifestations does the nurse monitor during rehydration of the client? Select all that apply. a. Blood serum glucose b. Blood pressure c. Pulse rate and quality d. Urinary output e. Urine specific gravity levels
B. Blood pressure C. Pulse rate and quality D. Urinary output E. Urine specific gravity levels The two most important areas to monitor during rehydration are pulse rate and quality and urine output; however, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is also important to monitor during rehydration. Blood glucose changes do not have a direct relation to a client's rehydration status.
Which electrolyte imbalance does the nurse anticipate in association with a serum magnesium reading of 1.1 mEq/L? a. Potassium 5.7 mEq/L b. Calcium 7.8 mg/dL c. Sodium 149 mEq/L d. Phosphorus 2.6 mg/dL
B. Calcium 7.8 mg/dL Hypocalcemia often occurs with hypomagnesemia. A calcium level of 7.8 mg/dL is low. A sodium level of 149 mEq/L is slightly elevated, but not related to the low magnesium level. A phosphorus level of 2.6 mg/dL is slightly low, but not related to hypomagnesemia.
Which nursing action does the nurse include in the care of an alert older adult who is mildly dehydrated? a. Advising the client and family that strict bed rest is recommended due to fall risk. b. Considering dietary restrictions and ability to swallow, and offering oral fluids every 2 hours. c. Restricting oral fluids if the client is incontinent. d. Assessing weight and vital signs every 4 hours.
B. Considering dietary restrictions and ability to swallow, and offering oral fluids every 2 hours. Oral fluid replacement is a priority when correcting mild to moderate dehydration in an alert client who can swallow. Because risk for falls is increased, the client should be offered assistance when ambulating. Bedrest is not recommended and may even contribute to other complications. Oral fluids should not be withheld due to incontinence. Initially, it is recommended to assess vital signs every 2 hours and weigh the client every 8 hours.
As adults age, which common physiologic change is likely to alter their hydration status? a. Adrenal gland growth b. Decreased muscle mass c. Increased thirst mechanism d. Poor skin turgor
B. Decreased muscle mass Decreased muscle mass causes decreased total body water, thus altering hydration status in the older adult. Adrenal growth is not a common age-related change. A decreased, not increased, thirst reflex is a common change related to aging. Poor skin turgor is a sign, not a cause, of altered hydration status.
A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? a. Draws blood for laboratory tests b. Elevates the head of the bed c. Places the extremities in a dependent position d. Puts the client in a side-lying position
B. Elevates the head of the bed Elevating the head of the bed will ease breathing for the client, so it should be done first. Although drawing blood for laboratory tests may be indicated, the nurse should perform interventions that will help with physiological changes caused by fluid overload first. Placing the extremities in a dependent position increases peripheral edema, and positioning the client in a side-lying position increases the work of breathing.
Laboratory results report a client's serum potassium at 5.6 mEq/L. What does the nurse immediately assess in the client? a. Level of consciousness b. Heart rate c. Bowel sounds d. Feet for paresthesias
B. Heart rate Cardiovascular changes, specifically bradycardia; tall, peaked T waves; rhythm changes to complete heart block; asystole; and ventricular fibrillation are life-threatening consequences of elevated potassium. The provider or Rapid Response Team may need to be notified if changes in heart rate and rhythm are assessed. Paresthesias in the arms and feet and increased intestinal motility are lower-priority signs of elevated potassium. Level of consciousness would not be affected.
When assessing the laboratory results of a client who has hypomagnesemia, for which additional electrolyte imbalance should the nurse monitor? a. Hyperkalemia b. Hypocalcemia c. Hypernatremia d. Hypophosphatemia
B. Hypocalcemia Hypocalcemia often occurs with hypomagnesemia, so the nurse would monitor for signs and symptoms of low calcium levels. Hypomagnesemia may increase potassium secretion in certain circumstances, leading the health care provider to be aware that replacement of magnesium is crucial before attempting to replace potassium if the client is deficient in both. Hypernatremia and hypophosphatemia are not related to hypomagnesemia.
Which component of a client history would most likely be associated with hyperphosphatemia? a. Chronic bronchitis b. Kidney failure c. Hyperparathyroidism d. Colon cancer
B. Kidney failure Hyperphosphatemia in acute or chronic kidney disease results from decreased loss of phosphorus due to the poor function of the kidneys. Chronic bronchitis does not affect phosphorus levels. Hypoparathyroidism (not hyperparathyroidism) may contribute to hyperphosphatemia. Certain cancer treatments, not the cancer itself, may cause hyperphosphatemia.
Which order does the nurse clarify with the provider based on the following available client data? Sodium 149 mEq/L Potassium 4.7 mEq/L Glucose 112 mg/dL Serum osmolality 316 mOsm/L HR 112 bpm RR 22 bpm BP 96/62 mm Hg Temp 38.1 C New-onset confusion Follows simple commands Reports fatigue Dry mucous membranes Presence of "tenting" of skin on back of hand a. Measure intake and output for 48 hours. b. No activity restrictions; ambulate ad lib. c. Encourage oral rehydration/intake. d. Report urine output less than 0.5 mL/kg/hr.
B. No activity restrictions; ambulate ad lib. The client data suggest dehydration. Safety is a priority concern in the care of this client. The nurse should clarify the activity order as fall precautions and activity limitations may be indicated for safety. The other orders are appropriate in the care of a client with dehydration.
The nurse is administering sodium chloride 0.9% (normal saline) intravenously to a client who is dehydrated. Which assessments does the nurse perform to evaluate the effectiveness of rehydration therapy? Select all that apply. a. Temperature b. Pulse rate and quality c. Neck vein distention d. Urinary output e. Bowel sounds
B. Pulse rate and quality D. Urinary output Pulse rate and quality as well as urinary output best reflect improving volume status with rehydration therapy. Temperature, neck vein distention, and bowel sounds are not indicators of an improving volume state.
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's: a. high magnesium. b. low calcium. c. high sodium. d. low potassium.
B. low calcium. Normal total serum calcium levels range between 8.9 and 10.1 mg/dL.
A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant? a. bounding pulse b. weight gain of 0.75 kg in a day c. increased blood pressure d. slightly distended neck veins
B. weight gain of 0.75 kg in a day Although increased blood pressure, bounding pulse, and distended neck veins are signs of ECF volume excess, rapid weight gain (more than 0.5 kg per day) is the most significant symptom indicating ECF volume excess. A weight gain of 1 kg reflects retention of 1 L of ECF. Additionally, because the veins are very distensible, large volumes of fluid can be retained without any increase in blood pressure or changes in pulse or neck veins.
The nurse is performing discharge dietary teaching for a client with hyperkalemia. Which statement does the nurse include in the teaching? a. "You may eat avocados, broccoli, and cantaloupe." b. "You may use salt substitutes." c. "You may eat apples, strawberries, and peaches." d. "You don't need to restrict dairy products."
C. "You may eat apples, strawberries, and peaches." The client with hyperkalemia should be instructed to consume foods low in potassium such as apples, strawberries, and peaches. The client should avoid foods high in potassium, which include avocados, broccoli, cantaloupe, and dairy products. Salt substitutes contain potassium.
A nurse identifies a nursing diagnosis of Excess Fluid Volume related to heart failure as evidenced by edema and weight gain. The nurse reviews the client's laboratory test results. Which plasma osmolality value would support the nurse's nursing diagnosis? a. 310 mOsm/kg b. 280 mOsm/kg c. 260 mOsm/kg d. 300 mOsm/kg
C. 260 mOsm/kg Normal osmolality is 280 to 300 mOsm/kg. Plasma osmolality decreases in water excess and elevates in water deficit. Therefore a result of 260 mOsm/kg would support the diagnosis of excess fluid volume.
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 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. +4 is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.
After receiving change-of-shift report, which client does the RN assess first? a. 26-year-old with nausea and vomiting who complains of dizziness when standing b. 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst c. 46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg d. 56-year-old with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL
C. 46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg The client with the history of receiving IV diuretics and having low blood pressure may be experiencing hypoperfusion caused by hypovolemia, and immediate assessment and interventions are needed. The client with nausea and vomiting, the client with an NG tube complaining of thirst, and the client receiving normal saline with an hourly urine output of 75 mL/hr have problems that are not urgent at this time.
Which person attending an all-day outdoor festival on a hot August day is at greatest risk for dehydration? a. 32-year-old man consuming alcoholic beverages b. 28-year-old woman with type 1 diabetes mellitus c. 72-year-old woman appearing to be at least 20 pounds overweight d. 68-year-old man who frequently wipes sweat from his forehead
C. 72-year-old woman appearing to be at least 20 pounds overweight The thirst mechanism is less sensitive in older adults, making them more at risk for dehydration. Women of any age have less total body water than men of similar sizes and ages, because men have more muscle mass than women and women have more body fat. (Muscle cells contain mostly water and fat cells have little water.) In addition, the 72-year-old woman is overweight, with an increased percentage of body fat compared to lean body mass, especially skeletal muscle. An obese person has less total water than a lean person of the same weight because fat cells contain almost no water. Although a 32-year-old man consuming alcohol, a 28-year-old with type 1 diabetes, and a 68-year-old who frequently sweats are at risk for dehydration, they are not as high-risk as the obese older adult.
The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is assigned to the LPN/LVN? a. 44-year-old with congestive heart failure (CHF) who has gained 3 pounds since the previous day b. 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L c. 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L d. 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest
C. 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L Although the 76-year-old client has poor skin turgor, the serum osmolarity indicates that fluid balance is normal; this client is the most stable of the four clients described and can be assigned to the LPN/LVN. The data about the 44-year-old with CHF who has gained 3 pounds since the previous day indicate reduced stability; assessments and interventions performed by an RN are needed. The data about the 58-year-old client with CRF and a serum potassium level of 6 mEq/L indicate reduced stability; assessments and interventions performed by an RN are needed. The data about the 80-year-old client with edema and congested lungs indicate that the client is not stable, and that assessments and interventions by an RN are needed.
Which medication may affect the assessment of a client's fluid balance after a surgical intervention? a. Penicillin twice a day b. Digoxin once a day c. Angiotensin-converting enzyme inhibitor twice a day d. Aspirin once a day
C. Angiotensin-converting enzyme inhibitor twice a day Urine output is used as an indicator of perfusion adequacy after surgery or other procedures. Medications used to manage hypertension such angiotensin-converting enzyme (ACE) inhibitors disrupt the renin-angiotensin II pathway, resulting in greater excretion of water and sodium in the urine. This may make it harder to use urine output as a primary measure of perfusion. Aspirin may prolong clotting. Penicillin and digoxin will not affect monitoring fluid balance postprocedure.
Which electrolyte imbalance should be anticipated and monitored in a client with hyperphosphatemia? a. Hypernatremia b. Hypokalemia c. Hypocalcemia d. Hypermagnesemia
C. Hypocalcemia Phosphorus and calcium have an inverse or reciprocal relationship. When one is increased, the other is usually decreased. Therefore, a client with hyperphosphatemia should be monitored for hypocalcemia. Hyperphosphatemia does not cause hypernatremia, hypokalemia, or hypermagnesemia.
A client reports painful muscle spasms in the lower legs at rest, a tingling sensation in the hands and lips, and abdominal cramping and diarrhea. The nurse reviews the client's laboratory results for the presence of which disorder? a. Hypophosphatemia b. Hypermagnesemia c. Hypocalcemia d. Hypernatremia
C. Hypocalcemia The primary symptoms of hypocalcemia are neuromuscular changes, specifically painful muscle cramps, and paresthesias that may spread to the face, progressing to tetany. Abdominal cramping and diarrhea may also occur. Muscle spasms in lower legs at rest, tingling sensation in the hands and lips, and abdominal cramping and diarrhea are not primary characteristics of hypernatremia, hypermagnesemia, or hypophosphatemia.
A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath (SOB), and 3+ pitting edema in her lower extremities. Her current medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her health care provider orders furosemide (Lasix) 5 mg IV push. Which client assessment determines that the medication is working? a. Decreased blood pressure (BP) b. Increased heart rate c. Increased urine output d. Weight gain
C. Increased urine output When giving Lasix, the nurse monitors the client for response to drug therapy, especially weight loss and increased urine output. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the most important assessment to be monitored. Urinary output is most important. Lasix may cause a decrease in heart rate as it lowers the client's body fluid, but this effect would take some time to note. Weight loss, rather than weight gain, is often the effect of Lasix, but it does not occur immediately.
A client has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the client? a. Administers 5 mEq intramuscularly (IM) b. Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr c. Infuses 10 mEq over a 1-hour period d. Pushes 5 mEq through a central access line
C. Infuses 10 mEq over a 1-hour period A dose of KCl 10 mEq given over 1 hour is appropriate for this client. A dose of KCl 200 mEq in 1 liter of normal saline infused at 100 mL/hr is too concentrated and can cause injury. Potassium is a severe tissue irritant and is never given by the intramuscular or subcutaneous route. Because rapid infusion of potassium can cause cardiac arrest, potassium is not administered through central lines.
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. Metabolic acidosis d. Metabolic alkalosis
C. Metabolic acidosis A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.
The nurse is assessing a client with hyponatremia. Which finding requires immediate action? a. Diminished bowel sounds b. Heightened acuity c. Muscular weakness d. Urine output of 35 mL/hr
C. Muscular weakness Muscle weakness in clients with hyponatremia requires immediate action. If muscle weakness is present, immediately check respiratory effectiveness because ventilation is dependent on adequate strength of the respiratory muscles. Excessive bowel sounds, not diminished bowel sounds, are expected in the client with hyponatremia, as well as mild confusion, not heightened acuity. A urine output of 35 mL/hr is normal (minimally) and does not require immediate action.
Which written order does the nurse clarify with the provider when caring for a client with a serum sodium level of 149 mEq/L? a. Institute seizure precautions. b. Weigh the client daily. c. Place the client on nothing by mouth (NPO) status. d. Monitor intake and output.
C. Place the client on nothing by mouth (NPO) status Ensuring adequate water intake is an important nutritional therapy in the treatment of hypernatremia; the nurse should ask for clarification of the NPO order. The other orders are appropriate in the management of clients with hypernatremia.
When caring for a client with hyponatremia, which intervention does the nurse implement? a. Intravenous administration of 0.45% normal saline b. Administration of furosemide (Lasix) c. Small-volume intravenous infusions of 3% normal saline d. 2-gram sodium diet
C. Small-volume intravenous infusions of 3% normal saline 3% saline is hypertonic and is given in small volumes to replenish serum sodium. 0.45% saline is hypotonic and will further dilute serum sodium levels. Furosemide (Lasix) causes sodium loss in the kidneys and would further contribute to hyponatremia. A 2-gram sodium diet restricts sodium intake; the goal of nutritional therapy with hyponatremia is to increase sodium intake.
A client is diagnosed with body fluid hypoosmolality. Treatment involves restricting his intake of free water. Which fluids would the nurse most likely restrict? Select all that apply. a. Tomato juice b. Milk c. Broth d. Apple juice e. Tea
D,E Management of water excess typically involves free water restriction. Limited fluids include water, coffee, tea, and simple fruit juices such as apple juice. More concentrated fluids such as milk, broth, or tomato juice may be given
A client is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond? a. "Fast thinking! She really needs to rest after the night she had." b. "Get the information now, or I'll report you for not doing your job." c. "Never mind—I will do it myself." d. "Weigh her now. We need her weight daily, at the same time."
D. "Weigh her now. We need her weight daily, at the same time." The nurse should educate the nursing assistant as to why obtaining the client's weight at the same time each day is important. Although the nursing assistant may be hesitant to wake the client, assessing the client's fluid balance is more important. The responses of telling the nursing assistant to get the information now or she'll be reported or that the nurse will get the information herself do not demonstrate good leadership. The assistant needs to understand the rationale for waking and weighing the client. She should not be dismissed and belittled by the nurse.
A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and oral potassium supplements. He tells the nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The health care provider requests laboratory specimens to be drawn and an isotonic IV to be started. Which IV fluid does the nurse administer? a. 0.45% saline b. 5% dextrose in 0.45% saline c. 5% dextrose in Ringer's lactate d. 5% dextrose in water (D5W)
D. 5% dextrose in water (D5W) 5% dextrose in water (D5W) is an isotonic solution. 0.45% saline is a hypotonic solution, while 5% dextrose in 0.45% saline and 5% dextrose in Ringer's lactate are hypertonic solutions.
The nurse instructs an older adult client to increase intake of dietary potassium when the client is prescribed which classification of drugs? a. Alpha antagonists b. Beta blockers c. Corticosteroids d. High-ceiling (loop) diuretics
D. High-ceiling (loop) diuretics High-ceiling (loop) diuretics are potassium-depleting drugs. The client should increase intake of dietary potassium to compensate for this depletion. Alpha antagonists, beta blockers, and corticosteroids are not potassium-depleting drugs.
The nurse is reviewing lab values for a client recently admitted to the medical-surgical unit. Which lab result is severely abnormal? a. Potassium, 3.5 mEq/L b. Sodium, 137 mEq/L c. Chloride, 107 mEq/L d. Magnesium, 6.2 mEq/L
D. Magnesium, 6.2 mEq/L A magnesium level of 6.2 mEq/L is greatly elevated. Clients with severe hypermagnesemia are in grave danger of cardiac arrest. The normal magnesium level is 1.3-2.1 mEq/L. The sodium and potassium results are within normal limits. The chloride level is just slightly elevated, with the normal range being between 98-106 mEq/L.
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 Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance
A client is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first? a. Auscultating bowel sounds b. Checking deep tendon reflexes (DTRs) c. Determining the level of consciousness (LOC) d. Obtaining a pulse oximetry reading
D. Obtaining a pulse oximetry reading Because hypokalemia may cause respiratory insufficiency and respiratory arrest, the client's respiratory status should be assessed first. Bowel sounds, DTRs, and LOC may change in a client with hypokalemia, but these changes are not immediately life-threatening.
Which newly written prescription does the nurse administer first? a. Intravenous (IV) normal saline to a client with a serum sodium of 132 mEq/L b. Oral calcium supplements to a client with severe osteoporosis c. Oral phosphorus supplements to a client with acute hypophosphatemia d. Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L
D. Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L Because minor changes in serum potassium level can cause life-threatening dysrhythmias, the first priority should be to administer potassium supplements to the client with hypokalemia. The electrolyte disturbance (sodium level of 132 and low phosphorus level) and the need for calcium in this client are not immediately life-threatening.
An older adult admitted with dehydration and a history of stress incontinence expresses embarrassment about the disorder and the need for absorbent undergarments. Which question about nutritional metabolic needs would be best to ask this client related to the reason for admission? a. What is your typical urinary elimination pattern and amount? b. How is your appetite? c. Have you noticed a change in the tightness of your shoes? d. What is your typical daily fluid intake and what types of fluids do you drink?
D. What is your typical daily fluid intake and what types of fluids do you drink? Asking the client about the amount and types of fluids will provide additional information as to how the client deals with incontinence through fluid management and possible causes for the dehydration. Asking the client about appetite, urinary pattern, and tightness of shoes is not helpful in assessing the client's current health problem.
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. nausea and vomiting c. fingerprinting over sternum d. distended neck veins
D. distended neck veins 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 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, moist 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. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.
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 physician, place the patient in upright position with feet dependent. b) Stop the transfusion immediately and keep the vein open with normal saline, notify the physician stat, administer antihistamine parenterally as needed. c) Stop the transfusion immediately and keep the vein open with normal saline, notify the physician, and treat symptoms. d) Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the physician, administer antibiotics stat.
a) Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.
A nurse is caring for a patient who has fluid imbalance related to the development of ascites. Which imbalances would the nurse monitor for in this patient? Select all that apply. a) Extracellular fluid volume deficit b) Protein deficit c) Metabolic alkalosis d) Sodium deficit e) Plasma-to-interstitial fluid shift f) Metabolic acidosis
a, b, d, e. Patients with fluid loss due to ascites are at risk for extracellular fluid volume deficit, protein deficit, sodium deficit, and plasma-interstitial fluid shift.
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? a) Risk for Infection related to inadequate personal hygiene b) Acute Confusion related to cerebral edema c) Pain related to surgical incision d) Constipation related to immobility
b) Acute Confusion related to cerebral edema 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 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 Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.
A nurse carefully assesses the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following? a) Kidneys b) Lungs c) Adrenal glands d) Blood vessels
b) Lungs The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.
Which client has more extracellular fluid? a) Adolescent man b) Newborn c) Female school-age child d) Adult woman
b) Newborn
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as a) Volume expander b) Total parenteral nutrition c) Blood transfusion therapy d) Cellular hydration
b) Total parenteral nutrition Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.
A decrease in arterial blood pressure will result in the release of: a) insulin. b) renin. c) protein. d) thrombus.
b) renin Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.
A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? a) Bread products b) Processed meat c) Apricots d) Dairy products
c) Apricots Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.
The primary extracellular electrolytes are: a) phosphorous, calcium, and phosphate. b) potassium, phosphate, and sulfate. c) sodium, chloride, and bicarbonate. d) magnesium, sulfate, and carbon.
c) sodium, chloride, and bicarbonate. The primary extracellular electrolytes are sodium, chloride, and bicarbonate.
A 70-year-old client is scheduled for a colonoscopy and is prescribed a bowel preparation solution. The nurse would be alert for which potential imbalance? Select all that apply. a) Hypophosphatemia b) Hypercalemia c) Hypocalcemia d) Hyperphosphatemia e) Hypokalemia f) Hyperkalemia
c, d, e Older adults are at increased risk for electrolyte imbalances during and after bowel preparation for procedures such as a colonoscopy or barium enema. Research has shown that bowel preparation solutions in clients over age 65 years are associated with vascular volume deficit, hyperphosphatemia, hypokalemia, and hypocalcemia.
A client has the following arterial blood gas results: pH: 7.33 PaCO2: 42 mm Hg HCO3: 19 mEq/L PaO2: 95 mm Hg Which imbalance would the nurse suspect? a) Metabolic alkalosis b) Respiratory acidosis c) Respiratory alkalosis d) Metabolic acidosis
d) Metabolic acidosis The results reveal metabolic acidosis, which is characterized by a pH lower than 7.35 and a plasma HCO3 concentration lower than 22 mEq/L. Respiratory acidosis is indicated by a low pH accompanied by an increased arterial concentration of carbon dioxide, which often is clinically defined as a PaCO2 of greater than 45 mm Hg. Respiratory alkalosis is present when a high pH is accompanied by a blood carbon dioxide concentration lower than 35 mm Hg. Metabolic alkalosis is characterized by a pH higher than 7.45 and a plasma HCO3 concentration above 26 mEq/L.
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; apply pressure with a sterile pad.
d) Put on gloves; remove the catheter; apply pressure with a sterile pad. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also apply pressure with a sterile gauze pad, secure the gauze with tape over the insertion site, and restart the IV in a new location.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a) a 47-year-old who had a colon resection yesterday and is reporting pain b) a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today c) a 60-year-old who is 3 days post-myocardial infarction and has been stable. d) a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
d) a newly admitted 88-year-old with a 2-day history of vomiting and loose stools 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. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).
