NUR 300 Sherpath : Electrolytes, Acids and bases, and fluid balance

The nurse is providing care to a patient with the following ABG values: pH 7.30, PaCO2 40 mm Hg, and HCO3- 20 mEq/L. Which should the nurse document in the medical record regarding this ABG?

Metabolic Acidosis

The nurse is evaluating the ABG results for a patient who is suspected of having an acid-base imbalance. The ABG analysis indicates a decreased pH, an increased PaCO2, and a normal HCO3-. Which conclusion by the nurse is accurate?

Respiratory acidosis A decreased pH, an increased PaCO2, and a normal HCO3- indicate that the patient is experiencing respiratory acidosis.

The nurse is assessing a patient with fluid volume deficit (FVD). Which clinical manifestation would suggest that the patient is experiencing hypertonic FVD?

The patient has become confused

Which questions should the nurse ask when conducting a health history assessment for a patient who has a potassium imbalance?

- "Do you take a diuretic, such as furosemide (Lasix)?" Furosemide is a potassium-wasting diuretic, which can cause hypokalemia. - "Do you use a salt substitute on your food?" Overuse of potassium-rich salt substitutes by people who have poor renal excretion may cause hyperkalemia.

The nurse is conducting a health history assessment for a patient who is diagnosed with hypermagnesemia. Which questions should the nurse in the assessment interview?

- "What type of laxatives do you use?" - "Do you use over the counter antacids?"

Which should the nurse assess for in all patients who are experiencing an acid-base imbalance?

- ABG analysis - Vital signs

Which patients are likely experiencing fluid volume deficit?

- An 86-year-old woman with a fever who has dry mucous membranes and decreased urination - An infant with diarrhea who has increased respiratory rate, tachycardia, and sunken fontanel - A 40-year-old woman with bleeding who has a weak, thready pulse and decreased skin turgor

A patient has developed edema. Which descriptions are accurate regarding this manifestation?

- Caused by excessive fluid in the interstitial space. - Dependent edema occurs in the sacral area of patient on bedrest. - Edematous tissue is quite fragile.

Which clinical manifestations should the nurse anticipate when assessing a patient who is diagnosed with hypernatremia?

- Confusion - Thirst - Lethargy - Seizures

A patient with vomiting and diarrhea has developed rapid onset isotonic fluid volume deficit. The patient can be expected to have which lab data results?

- Elevated RBC Elevated RBC levels show fluid volume deficit that developed rapidly. Increased RBC indicates a concentration of blood cells and too little circulating fluid. Increased BUN and - Creatinine The increased BUN and Creatinine are a result of too little fluid passing through the kidneys.

An acutely ill patient is brought into the urgent treatment center by a family member. Which patient assessments would suggest a significant fluid volume deficit?

- Elevated serum BUN and creatinine - Rapid, weak, thready pulse - Dry, cracked lips and furrows on the tongue

Which nursing actions should the nurse perform when analyzing an ABG during the assessment process for a patient who is suspected of having an acid-base imbalance?

- Examining oxygenation status - evaluating the pH - Assessing PaCO2 and HCO3- - Determining compensation

The nurse suspects that a patient has developed a hypertonic fluid volume deficit from receiving a large volume of hypertonic IV fluids. The nurse should expect to see which lab test result?

- Increased BUN and creatinine - Elevated serum osmolality

Increased circulating volume The bounding peripheral pulses and jugular venous distention are caused by increased circulating fluid volume, which occurs when excessive fluid is retained in the cardiovascular system.

- Seizures - Confusion

The nurse is assessing a patient who is diagnosed with respiratory acidosis. Which cardiovascular finding does the nurse anticipate when assessing the cardiovascular system?

- Tachycardia - Dysrhythmia

Which clinical manifestation does the nurse anticipate when assessing a patient who is experiencing respiratory alkalosis?

- Tachypnea

A patient presents to the emergency department (ED) with a serum phosphate concentration of 3.1 mEq/L. Which should the nurse assess this patient for based on this laboratory value?

- Tetany - Hyperreflexia - Muscle Cramps

Place the steps the nurse uses to analyze ABGs in the correct order.

- evaluate the PaO2 and O2 saturation levels to determine if hypoxemia is occurring. - evaluate the pH to determine if it is acidotic, alkalotic, or within normal limits. - evaluate the PaCO2 and HCO3- to determine if the imbalance is respiratory or metabolic. - determine if compensation is occurring.

The nurse has been assigned to an adult patient with isotonic fluid volume deficit and performing her shift assessment on the patient. The nurse can anticipate which clinical findings?

- hypotension - flat neck veins when supine - low urine output

A nurse is asked to assess a patient for fluid volume deficit. The patient reports that he has lost 10 kg of total body weight in the last 48 hours due to vomiting and diarrhea. Based on the relationship between volume and weight, about how much fluid has this patient lost?

10 liters of fluid.

Which PaO2 value indicates moderate hypoxemia?

40-60 mm Hg

The nurse is providing care to a patient whose serum potassium level is 5.2 mEq/L. Which clinical manifestation should the nurse monitor the patient for during the assessment?

Bradycardia A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia.

Match the physical assessment with the data indicating an electrolyte imbalance.

Chvostek Sign - spasm of the facial muscles when facial nerve is tapped Trousseau Sign - spasm of the hand and wrist muscles after blood pressure cuff is inflated Deep Tendon Reflex - Foot kicks wildly when patellar tendon is tapped

Which neurological assessment, performed by tapping the side of the face, should the nurse perform for a patient with risk factors for hypocalcemia?

Chvostek sign Chvostek sign is a neurological assessment that is performed by tapping the side of the face over the facial nerve. A positive Chvostek sign, spasm of the facial muscle, indicates increased neuromuscular excitability, consistent with hypocalcemia.

Which neurological clinical manifestations are associated with metabolic acidosis?

Confusion and lethargy

The nurse is assessing a 35-year-old patient who is at risk for developing fluid volume excess. Which data would support the presence of FVE in an adult patient?

Crackles auscultated in lung bases

The nurse should expect that a patient with a serum potassium concentration of 3.1 mEq/L would have which clinical manifestation?

Decreased bowel sounds A serum potassium concentration of 3.1 mEq/L indicates hypokalemia. Decreased bowel sounds are associated with hypokalemia because intestinal smooth muscle becomes weak.

In a patient with fluid volume deficit, which clinical manifestation would be due to decreased interstitial fluid?

Decreased skin turgor Skin turgor is altered by interstitial fluid levels. Assessing skin turgor is a quick assessment for fluid deficit.

A patient has developed fluid volume excess. The nurse is aware that the increase in the patient's interstitial fluids can lead to which manifestation?

Dependent edema

Which test should the nurse anticipate for a patient with hyperkalemia?

Electrocardiogram

During the morning patient assessment the nurse finds bounding peripheral pulses and jugular venous distention. The nurse is aware that these are clinical manifestations caused by what type of fluid imbalance?

Increased circulating volume The bounding peripheral pulses and jugular venous distention are caused by increased circulating fluid volume, which occurs when excessive fluid is retained in the cardiovascular system.

A patient has developed edema as a result of fluid volume excess. The nurse is aware that the underlying cause of this fluid imbalance is which primary cause of edema?

Increased hydrostatic pressure Increased hydrostatic pressure is the pressure exerted against vessel walls as blood rushes through the vasculature. As pressure increases with fluid volume excess, fluid leaves the blood vessels, entering the interstitial spaces.

A patient has developed neurologic manifestations related to hypertonic fluid volume deficit. The nurse is aware that these manifestations are caused by what underlying problem?

Increased serum osmolality causes water to shift out of brain cells by osmosis As water shifts out of the cells, they shrink and become dysfunctional, causing neurologic manifestations.

Match each laboratory test with the information it provides.

Indicator of overall renal function - BUN and creatinine Helps determine hydration status, useful in managing fluid requirements - serum osmolality Measure of the oxygen carrying capacity of the blood - RBC and H&H Measure of the concentration of the solutes in the urine - urine osmolality

The nurse is providing care to a patient who is diagnosed with end-stage renal disease. Which clinical manifestation assessed by the nurse indicates the patient is experiencing hyperphosphatemia?

Irritated and itchy eyes In patients who have end-stage renal disease, hyperphosphatemia will cause calcium phosphate crystals to form in soft tissues, causing itching or irritated eyes.

Which assessment finding causes the nurse to suspect that a patient is experiencing metabolic acidosis?

Kussmaul respirations Kussmaul respirations are frequent, deep breaths that constitute a compensatory mechanism in an effort to breathe out more carbon dioxide. This is an assessment finding that would cause the nurse to suspect that the patient is experiencing metabolic acidosis.

The nurse should expect that a patient with severe hypocalcemia would have which clinical manifestation?

Laryngospasm Laryngospasm is a clinical manifestation of severe hypocalcemia.

A patient presents with muscle twitching and tetany. Ten minutes after hospital admission, the patient experiences a seizure. Which acid-base imbalance should the nurse suspect?

Metabolic alkalosis

The nurse notes that an assigned adult patient has experienced a 5% weight gain over the last 24 hours. Taking the patient's data into consideration, the nurse concludes that it is fluid weight gain. What degree of excess does this patient have?

Moderate FVE Moderate FVE is a weight gain of 5%.

Which acid-base imbalance manifests with tachypnea and light-headedness?

Respiratory alkalosis

The nurse is assessing a patient with hypomagnesemia and anticipates which manifestations?

Seizures Nystagmus Both of these are a result of increased neuromuscular excitability

A patient presents to the emergency department with severe bilateral lower extremity weakness and shallow respirations. Heart rate and rhythm are normal and the patient is alert. Which laboratory test should the nurse anticipate based on the current data?

Serum potassium The nurse would anticipate a serum potassium concentration test for this patient. Hypokalemia causes bilateral quadriceps muscle weakness that may ascend to weaken the respiratory muscles.

A patient who has been ill with vomiting and diarrhea has experienced a rapid weight loss of 8% of total body weight. How would this be categorized on the dehydration scale?

Severe dehydration

Which assessment finding would support the diagnosis of hypocalcemia?

Trousseau Sign Indicates a neurologic symptom of spasm in the muscle

A nurse is obtaining a health history on a newly-admitted patient. Which patient responses should alert the nurse to the possibility of a fluid volume imbalance?

Weight gain of 2 kg since yesterday morning An increase of 1 or more kg over a 24 hour period is a very strong indicator of a fluid volume excess.

Match the normal values with the appropriate ABG parameter.

pH : 7.35 - 7.45 PaCO2 : 35-45 mmHG PaO2 : 80-100 mmHg HCO3- : 22-26 mEq/L