ATI- Fluid, Electrolyte and acid-base regulation, ATI Fluid, Electrolyte, and Acid-Base Regulation
Metabolic Acidosis
(bicarbonate deficit) characterized by low pH (increased H+ concentration) low plasma bicarbonate concentration (<22 mEq/L) Causes: * GI or kidney loss bicarbonate *accumulation of fixed acid *low blood glucose Manifestations: tachypnea, confusion, hypotension and decreased cardiac output
Metabolic Alkalosis
(bicarbonate excess) characterized by: * high pH (decreased H+ concentration) * high plasma bicarbonate concentration (>26 mEq/L) Causes: *Loss of hydrogen ions (i.e. vomiting) *Kidney failure (not excreting bicarb) *Diuretics *Hypokalemia Manifestations: similar to hypocalcemia and hypokalemia *Treatment focuses on the underlying metabolic disorder, K+ and fluid replacement
A nurse is reinforcing teaching with a newly licensed nurse about using the nursing process when caring for a client who has an acid-base imbalance. The nurse should include that the stages of the nursing process should be performed in what order? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Data Collection 2. Evaluation 3. Implementation 4. Planning
1,4,3,2
Magnesium (Mg2+) normal range
1.3-2.1 mEq/L
Sodium (Na+) normal range
136-145 mEq/L
A nurse is preparing to administer 1,950 mL of 0.45% sodium chloride IV to infuse over 13 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
150 mL/hr Rationale: 1950mL/13hr = 150mL/hr
A nurse is preparing to administer 4,200 mL of intravenous fluids to a client to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
175 mL/hr Rationale: 4200mL/24hr = 175mL/hr
Potassium (K+) normal range
3.5-5.0 mEq/L
true
62 yr old with congestive heart failure is at risk for developing hypernatremia, true or false?
Calcium (Ca) normal range
9.0-10.5 mg/dL
respiratory acidosis
A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2.
Vasopressin
A hormone excreted by the hypothalamus in the brain that maintains blood pressure and fluid volume. Also knows as antidiuretic hormone (ADH)
respiratory alkalosis
Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.
Chvostek's sign
Cheek, facial spasm when Cheek is tapped associates with hypocalcemia
sodium
Electrolyte that supports the function of nerves and muscles, maintains normal blood pressure, and regulates fluid balance in the body
water
Excess_________ in the body—rather than a lack of sodium—is the most common cause of hyponatremia, as the presence of too much dilutes the sodium level.
Electrolytes
Fluid excess (over hydration) causes dilution of ___________________ and red blood cells
A patient admitted with hypovolemia asks the nurse the cause of this condition. The nurse identifies which of the following as risk factors for hypovolemia? Select all that apply.
Hemorrhage Vomiting Constipation Liver cirrhosis Burns Dry skin
0.9 %
How much salt are we made up of
osteopenia
Hypocalcemia can lead to ________________, also known as low bone mass, and increase the risk of bone fractures and osteoporosis.
hemodialysis
If the elevated potassium level is due to renal failure, _______________ may be required. Other treatment options for hyperkalemia include medications such as calcium gluconate and diuretics.
cerebral
In treating hypernatremia, it is important to decrease the sodium level slowly to prevent ____________ edema
water
It is critical to maintain the balance of __________ in the body to prevent hypovolemia, dehydration, tachycardia, tachypnea, confusion, headache, kidney stones, and numerous other medical complications.
Hypermagnesemia
Magnesium level above expected reference range of 1.3 to 2.1 mEq/L. a rare occurrence but can be a dangerous electrolyte imbalance
Hypomagnesemia
Magnesium level below expected reference range of 1.3 to 2.1 mEq/L.
resin
Medication taken to decrease potassium levels via bowel movements.
diabetes
Neonates and infants are at greater risk for hypocalcemia if they are born to mothers who have ______________, pre-eclampsia, or hyperparathyroidism.
urine
Osmolality can also be measured using ________and is used to determine renal function as well as hydration status.(expected range for urine osmolality is 50 to 1,200 mOsm/kg)
hemodialysis
Process of filtering waste from the blood using a machine.
serum
Routine __________ electrolyte tests—either BMP or CMP—are used to measure the level of sodium and water in the blood.
blood
Routine ____________ tests such as the BMP or CMP are used to measure potassium levels. The provider may prescribe an ECG to determine if the level of potassium is affecting the rhythm of the heart.
diuretic
Taking a loop___________ puts a client at risk for hypokalemia because these medications promote potassium loss through the kidneys.
trousseau sign
Test that can indicate low calcium or magnesium levels and spasms in the wrist and hand (carpopedal spasms) when a blood pressure cuff is inflated above the systolic blood pressure.
ECG
The client should be on continuous ________monitoring while receiving IV potassium. The client's potassium lev
osmosis
The final mechanism used to maintain water balance is ___________, which allows for the passive flow of water between the compartments of the body to maintain an equilibrium.
potassium
The most common cause of hypokalemia is loss of _______________from the kidneys or gastrointestinal tract.
cancer
The most common causes of hypercalcemia are hyperparathyroidism and ___________
Hypocalcemia
Tingling around the mouth and muscle spasms are both indications of
Patient Education
_________ ____________ for those with fluid and balances includes: *identifying and reporting early signs and symptoms of dehydration or fluid access to the HCP *reporting elevated temperature that can lead to fluid loss *recognizing foods high in sodium *using diuretics and potassium, supplements correctly, and *reporting any rapid weight gain
Data Collection
_________ _____________ for patients with fluid and electrolyte imbalances includes: *comparing intake & output, *monitoring rapid, weight, loss, or gain, *edema, *lung sounds, *skin turgor, and *reviewing electrolyte levels on laboratory reports.
Serum osmolality
___________ ____________ is the most frequently used laboratory indicator of the body's fluid status. (expected range is 285 to 295 mOsm/kg)
Hypocalcemia
______________ occurs when serum calcium levels are below 9 mg/dL and ionized levels are less than 4.5 mg/dL.
calcium gluconate
_______________ _______________ should be administered for a pt with positive trousseau sign
Hypercalcemia
_____________________ occurs at a serum calcium level greater than 10.5 mg/dL and an ionized calcium level greater than 5.6 mg/dL. Elevated serum calcium levels can lead to development of kidney stones, weaken bones, and affect the function of the heart and brain.
electrolytes
_____________________are responsible for the following functions within the body: *Maintaining the balance of water in the body *Balancing the blood pH (acid-base) level *Moving nutrients into the cells *Moving wastes out of the cells *Maintaining proper function of the body's muscles, heart, nerves, and brain)
magnesium
___________________is the body's second most common intracellular electrolyte. As with calcium, much of the body's store, 50% to 60%, is located in the bones. It's role in the body is to assist in the regulation of nerve and muscle function, maintain blood pressure and serum glucose levels, support bone and teeth health, and synthesize protein, DNA, and RNA.
Hyponatremia
__________________occurs when levels of sodium fall below 136 mEq/L. Critical values occur at less than 120 mEq/L.
fluid intake
a bedridden client has a calcium level of 13, the most important nursing action is to provide passive ROM exercises and encourage ____________ ____________
renal failure
a client admitted from the ER has a potassium level of 6, this finding is a result of acute _______ _________.
seizure
a client is admitted with a sodium level of 110, Pt should be placed on ____________ precautions
bowel movements
a client with a k+ level of 5.5 receives Kayexalate, the priority nursing action is to monitor ____________ _______________
tendon reflexes
a pt with a serum Ca level of 12.5 mg/dL would require immediate follow up for diminished deep _________ _____________
A nurse is participating in a blood drive and is taking a donation from a client who has type O+ blood. The client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make? a. "You can receive a blood donation from donors with type O- and type O+ blood." b. "You can receive a blood donation from donors with type B- and type A+ blood." c. "You can receive a blood donation from donors with type B- and type AB+ blood." d. "You can receive a blood donation from donors with type AB- and type A- blood."
a. "You can receive a blood donation from donors with type O- and type O+ blood." Rationale: Clients who have type O+ blood can only receive blood from donors who have type O- or O+ blood.
A nurse is calculating a client's intake and output for the last 4 hr. The client consumed 480 mL of water and 240 mL of coffee. The client has also received IV fluids for 4 hr infusing at 100 mL/hr. Which of the following amounts represents the client's intake over the last 4 hr? a. 1,120 mL b. 720 mL c. 480 mL d. 580 mL
a. 1,120 mL Rationale: 480mL + 240mL +4hr (100mL/hr) = 1120mL
A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia? a. A client who has vomited four times during the last 8 hr. b. A client who requested an extra breakfast tray to eat. c. A client who can ambulate without assistance. d. A client who reports extreme thirst.
a. A client who has vomited four times during the last 8 hr. Rationale: Nausea & vomiting are early manifestations of hypomagnesemia. Other manifestations of hypomagnesemia include decreased appetite & weakness which could make it difficult to ambulate. Extreme thirst is a manifestation of hypernatremia
A nurse is participating in a blood drive and is taking a donation from a client who has type A- blood. The client asks the nurse what blood types can receive their blood donation. Which of the following responses should the nurse make? (Select all that apply.) a. A+ b. B+ c. O+ d. AB- e. AB+ f. A-
a. A+ d. AB- e. AB+ f. A-
A nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients? (Select all that apply.) a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid d. Eating watermelon daily e. Eating cucumbers with each meal
a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid Rationale: The nurse should identify that an older adult client who has decreased kidney function, decreased thirst response, decreased total body fluid is at risk for dehydration
A nurse is reviewing arterial blood gas (ABG) values for a client who is experiencing metabolic acidosis. Which of the following ABG values should the nurse expect? (Select all that apply.) a. HCO3- 19 mEq/L b. pH 7.29 c. PaCO2 49 mm Hg d. pH 7.49 e. PaCO2 35 mm Hg
a. HCO3- 19 mEq/L b. pH 7.29 e. PaCO2 35 mm Hg
A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for the client? a. Increase the carbon dioxide level. b. Increase the respiratory rate. c. Increase the bicarbonate level. d. Increase the pH level.
a. Increase the carbon dioxide level
A nurse on a pediatric floor is reinforcing teaching with a newly licensed nurse about IV therapy. Which of the following information should the nurse include? a. Perform range of motion exercises on the extremity containing the IV site. b. Shave the client's hair if the IV is to be placed in the scalp. c. IV sites can be placed in the lower extremities up to the age of 2 years. d. Monitor the IV site, tubing, and connections every 4 hr.
a. Perform range of motion exercises on the extremity containing the IV site.
A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective? (Select all that apply.) a. The client states their muscle spasms are absent. b. The client reports a headache. c. The client denies being confused. d. The client reports being nauseated. e. The client reports feeling tired.
a. The client states their muscle spasms are absent. c. The client denies being confused. Rationale: The absence of muscle spasms & client reporting that they are not confused is an indication of adequate sodium levels
A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene? a. The nurse selects 0.45% sodium chloride to use to prime the tubing. b. The nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion. c. The nurse uses tubing with a filter for the blood transfusion. d. The nurse discards the tubing after the first unit of blood is completed.
a. The nurse selects 0.45% sodium chloride to use to prime the tubing. Rationale: The charge nurse should intervene if the newly licensed nurse selects 0.45% sodium chloride to use to prime the tubing. The nurse should identify that 0.9% sodium chloride is the only IV solution that should be used to prime the tubing for blood administration
Hypervolemia
abnormal increase in the volume of blood plasma in the body
skin
an MD has charted 800ml of insensible fluid loss on a pt, this loss can occur through the _______
metabolic alkalosis
an NG tube is connected to low intermittent suction for two days, which acid-base balance?
A nurse is reviewing prescriptions for a client who needs intravenous fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate? a. 3% sodium chloride solution b. 0.9% sodium chloride solution c. 0.45% sodium chloride solution d. Dextrose 10% in water
b. 0.9% sodium chloride solution Rationale: A 0.9% sodium chloride solution is isotonic & is used for hydration needs such as from vomiting, diarrhea, hemorrhage & shock. 3% sodium chloride solution is hypertonic & is used for emergent replacement solutes experiencing manifestations of hyponatremia. 0.45% sodium chloride solution is hypotonic & is used to treat hypernatremia & DKA. Dextrose 10% in water is hypertonic & is used to treat hypoglycemia
A nurse is assisting in the care of a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first? a. Initiate continuous cardiac monitoring. b. Elevate the head of the client's bed. c. Instruct the client to deep breathe and cough. d. Initiate continuous SpO2 monitoring.
b. Elevate the head of the client's bed Rationale: The 1st action the nurse should take when using the airway, breathing, circulation approach to client care is to elevate the HOB. Placing the client in a Fowler's or semi-Fowler's position will promote effective breathing & chest expansion
A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following complications should the nurse monitor? a. The need for multiple IV sticks b. Infection at the access site c. Dehydration d. Infiltration
b. Infection at the access site Rationale: The nurse should monitor the client who has a PICC for complications, such as infection at the access site & blood clots. It is important for the nurse to use aseptic technique when accessing & flushing the PICC line & during dressing change
A nurse is reviewing laboratory results for a client and notes the following arterial blood gas (ABG) values: pH 7.31, PaCO2 49 mm Hg, and HCO3- 25 mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis
b. Respiratory acidosis
A nurse is collecting data from a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following reports from the client is an indication that they may have a fluid or electrolyte imbalance? a. The client reports working in a warehouse in 21.1° C (70° F) temperature. b. The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. c. The client reports that their provider decreased their diuretic dose. d. The client reports they had a 24-hr intestinal virus 2 weeks ago.
b. The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. Rationale: The nurse should identify that working outside in high temperature for an extended period can cause profuse sweating & lead to a fluid & electrolyte imbalance
A nurse is assisting in the care for a client who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge catheter than the #20-gauge being replaced. Which of the following gauge catheters should the nurse recommend using? a. #16-gauge b. #18-gauge c. #22-gauge d. #14-gauge
c. #22-gauge Rationale: As the gauge # increases, the actual catheter size decreases
A nurse is assisting in the care of a client who has heart failure and a prescription to receive a unit of packed red blood cells. The nurse should plan for the blood to infuse over which of the following lengths of time? a. 1 hr b. 2 hr c. 4 hr d. 6 hr
c. 4 hr Rationale: The transfusion should be administered slowly (max time of 4hrs) to avoid increasing the workload of the heart
A nurse is caring for a client who has the following arterial blood gas (ABG) values: pH 7.44, PaCO2 37 mm Hg, and HCO3- 24 mEq/L. The nurse should identify that these values are an indication of which of the following? a. Metabolic acidosis b. Respiratory acidosis c. Acid-base balance d. Respiratory alkalosis
c. Acid-base balance Rationale: The nurse should identify that this client's ABG values are within the expected reference range
A nurse is reviewing the latest arterial blood gas (ABG) values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process? a. Planning b. Data collection c. Evaluation d. Implementation
c. Evaluation Rationale: Reviewing the client's ABG values is part of the evaluation stage of the nursing process
A nurse is reviewing a client's laboratory results. Which of the following results should the nurse report to the provider? a. Potassium 4.5 mEq/L b. Sodium 138 mEq/L c. Magnesium 3 mEq/L d. Calcium 10 mg/dL
c. Magnesium 3 mEq/L Rationale: A magnesium level of 3 mEq/L is above the expected reference range of 1.3 to 2.1 mEq/L
A nurse is reviewing the arterial blood gas (ABG) values for a client and notes the following results: pH 7.49, PaCO2 39 mm Hg, and HCO3- 35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis
c. Metabolic alkalosis
A nurse is assisting in the care of a client who has a prescription to receive one unit of packed red blood cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood bank. Which of the following actions should the nurse take? a. Return the blood unit as it is not compatible with the client's blood type. b. Stay with the client for 15 min prior to starting the blood transfusion. c. Verify the unit of blood with another nurse. d. Prime the blood tubing with 0.45% sodium chloride.
c. Verify the unit of blood with another nurse. Rationale: The unit of blood is compatible with the client's blood type. However, the nurse should ensure that the blood unit had been verified by 2 nurses before initiating the transfusion
hyponatremia
caused by excessive diaphoresis (sweating)
A nurse is assisting an RN who is preparing to start an IV for a client who has a high risk for bleeding. Which of the following actions should the nurse take? a. Apply a cold compress to the selected IV site. b. Ask the client to hold the extremity up prior to searching for an IV site. c. Ask the client to spread the fingers of the selected extremity. d. Apply a blood pressure cuff set to 30 mm Hg.
d. Apply a blood pressure cuff set to 30 mm Hg Rationale: Instead of using a tourniquet, the nurse should apply a BP cuff set to 30 mm Hg prior to starting an IV for this client. This will help protect the client's extremity from bruising & bleeding
A nurse is collecting data on a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications? a. Phlebitis b. Extravasation c. Air embolism d. Circulatory overload
d. Circulatory overload Rationale: The nurse should identify that a client who has been receiving IV therapy & whose daily weight has increased is at risk for circulatory overload. Other indications of circulatory overload include tachycardia, increased BP, edema, cough & tachypnea
A nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider? a. Dry mucous membranes b. Decreased urine output c. Report of thirst d. Decrease in level of consciousness
d. Decrease in level of consciousness Rationale: This is an indication that the hypovolemia has progressed to a critical level & requires immediate interventions Dry mucous membranes, decreased urine output, report of thirst are non-urgent because it is an early & expected finding of hypovolemia
A nurse is reviewing a client's latest arterial blood gas (ABG) report. Which of the following values should the nurse identify as the priority to report to the provider? a. pH 7.37 b. PaCO2 43 mm Hg c. HCO3- 27 mEq/L d. PaO2 76 mm Hg
d. PaO2 76 mm Hg Rationale: This value is below the expected reference range of 80 to 100 mm Hg & could be an indication the client is decompensating
A nurse has completed collecting data for a client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take next? a. Implementation b. Re-collection of data c. Evaluation d. Planning
d. Planning Rationale: After assessing & analyzing data for a client who has an acid base imbalance, the nurse should move into the planning stage of the nursing process & establish goals & outcomes for the client
PTH (parathyroid hormone)
decreased _______ may lead to a need for lifetime supplementation of calcium
Hypovalemia
decreased blood volume due to body fluid or blood loss
Hyperkalemia
excessive potassium in the blood
blood pressure
fluid volume excess sign/symptom to expect for pt with audible crackles and dyspnea? increase in __________ ____________
canteloupe
fruit that should be avoided by a pt with hyperkalemia
hyponatremia
ham and cheese on white bread is a good diet for a pt with _________________ (imbalance)
hypocalemia
hypo parathyroid issue, tingling down extremities and around mouth, what electrolyte imbalance?
seizure
initiate _____________ precautions for sever hypernatremia
metabolic
kidneys are a ________________ related condition
ROME method
look at pH, pCO2, and HCO3 Respiratory is Opposite Metabolic is Equal if pH is opposite pCO2, its a respiratory problem if pH is on the same side as HCO3, it is metabolic
respiratory
lungs are a _______________________ related condition
urine output
measure the patient's ______________ _____________ prior to administration of IV potassium
calcium
most abundant mineral in the body, plays a role in the following activities: mineralization of bone, muscle contraction, nerve transmission, clotting of blood, hormone secretion, and normal functioning of the heart.
renal
most common cause of hyperkalemia is ________ failure
consent
need informed _____________ before administering a blood transfusion
35-45
normal CO2 values
22-26
normal HCO3 values
95-100%
normal O2 saturation
80-100
normal pO2 values
tachycardia
observe pt for ________________ who has a serum potassium level of 3.0 mEq/L
Alkilosis
pH above 7.45
Acidosis
pH below 7.35
metabolic acidosis
pH: 7.33 PCO2: 35 HCO3 : 17 indicates _____________ _____________
hypercalcemia
pallor and bradycardia would indicate ________________________``
Trosseau's
pt developing carpal tunnel, probably caused by _____________________ sign
hyponatremia
pt with a headache, weakness and irribility: which imbalance?
sodium
pt with an NG tubes labs are K:4.5 and Na: 132 the tube should be flushed with ____________ chloride
kalemia
pt with an NGT s at risk of hypo _______________
bicarbonate
pt with prolonged diarrhea: should expect decreased pH and _______________________
fluid
pt with renal failure is at risk for _______ volume excess
true
pt with serum calcium of 7.4 mg/dL should: Laryngeal spasm should be followed up on fast, True or false?
Bradydysrhythmias
pt with serum potassium of 5.8 mEq/L, nurse should monitor pt for __________________________
potassium
pt with vomiting and diarrhea: should monitor serum ___________________
ABG sample
reports the status of oxygenation and acid-base balance of the blood
Diffusion
the process by which molecules move from an area of higher concentration to an area of lower concentration
true
tingling of the extremities and muscle spasms should be expected in a pt with hypocalcemia, true or false?
sodium
what should be included in the plan of care for fluid volume excess: restrict the client's ______________ in diet
water reabsorption
when osmolality increases, the hypothalamus triggers the release of ADH from the posterior pituitary. ADH acts on the kidnesys to increase ____________ _______________, decrease urine excretion and increase fluid volume in the body
