Chapter 13 Fluid and Electrolytes, ABGs
The most characteristic manifestations of hypocalcemia and hypomagnesemia.
tetany
What clinical indication of hypophosphatemia does the nurse assess in a patient?
tetany
Which item of assessment data obtained by the home care nurse suggests that an older adult client might be dehydrated?
the client states that he fells lightheaded when he gets out of bed or stands up
A client is admitted with mixed respiratory and metabolic acidosis secondary to bronchitis an diabetic ketoacidosis. The nurse evaluates that teaching about the clients confusion was effective when a family member makes which statement?
the confusion should clear when oxygen and electrolyte levels are normal
A client is admitted with hyponatremia. Four hours after the initial assessment, the nurse notes that the client has a new hyperactive bowel sounds in all four quadrants. What analysis about the clients condition is correct?
the hyponatremia is worse
A patient with cancer is being treated on the oncology unit for bilateral breast cancer. The patient is undergoing chemotherapy. The nurse notes the patient's serum calcium level is 12.3 mg/dl. Given this lab finding, the nurse should suspect which of the following statements?
the patient's malignancy is causing the electrolyte imbalance
The healthcare provider has prescribed a hyptonic IV solution for a patient. Which IV solution should the nurse administer? a) 0.45% sodium chloride b) 0.90% sodium chloride c) 5% dextrose in water d) 5% dextrose in normal saline solution
0.45% sodium chloride
What factors contribute to hypocalcemia?
massive administration of citrated blood, pancreatitis, kidney failure, aminoglycoside administration
A patient is ordered to receive hypotonic solution to provide free water replacement. Which solution will the nurse anticipate administering?
0.45% normal saline (NaCl)
A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause?
"do you use diuretics or laxitives?"
The average daily urinary output in an adult is? a) 1-2 liters b) 3-5 liters c) 2-4 liters d) 0.5 -1 liters
1-2 liters
The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? a) 115 mEq/L b) 130 mEq/L c) 145 mEq/L d) 160 mEq/L
115 mEq/L
A patient who is semiconcious presents with restlessness and weaknes. The nurse assesses a dry, swollen tongue and a body temperature of 99.3. The urine specific gravity is 1.020. What is the most likely serum sodium value for this patient? a) 110 mEq/L b) 140 mEq/L c) 155 mEq/L d) 165 mEq/L
155 mEq/L
The nurse is caring for a patient in the ICU following a saltwater near-drowning event. The client is resless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be what?
155 mEq/L
A patient is admitted with a diagnosis of kidney injury. The patient reports "stomach distress" and describes ingesting several antacids over the past 2 days. Blood pressure is 110/70 mm Hg, face is flushed, and the patient is experiencing generalized weakness. Which is the most likely magnesium level associated with the symptoms the patient is having?
5 mEq/L
A patient is admitted with severe vomiting for 24 hours as well as weakness and "feeling exhausted." The nurse observes flat T waves and ST-segment depression on the electrocardiogram. Which potassium level does the nurse observe when the laboratory studies are complete?
2.0 mEq/L
A client is taking feurosimide and becomes confused. Which potassium level does the nurse correlate with this condition?
2.9 mEq/L
A patient's serum sodium concentration is within normal range. What should the nurse estimate the serum osmolality to be? a) <136 mOsm/kg b) 275-300 mOsm/kg c) >408 mOsm/kg d) 350-544 mOsm/kg
275-300 mOsm/kg
About _____% of the 6 liters of blood is made up of ______? a) extracellular b) plasma c) 65 d) 50
50; plasma
The upper and lower blood pH levels that are incompatible with life are ____________ on the lower end and ___________ on the upper end. a) 6.5 b) 7.2 c) 6.8 d) 7.8
6.8; 7.8
About ________% of total body fluid is in the intracellular space. a) 40 b) 55 c) 66 d) 80
66%
What is the normal pH of blood?
7.35-7.45
A patient presents to the ER experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient's pH value to be what?
7.50
Cardiac effects of hyperkalemia are usually present when the serum potassium level reaches __________ meq/L a) 4 b) 3 c) 2 d) 8
8
In a patient with excess fluid volume, hyponatremia is treated by restricting fluids to how many milliliters in 24 hours? a) 400 b) 600 c) 800 d) 1200
800
What is the normal oxygen saturation for arterial blood? a) 88% b) 77% c) 90% d) 95%
95%
The nurse monitors the client with which condition most carefully for metabolic alkalosis?
A critical illness receiving total parenteral nutrition
The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate?
Assess turgor on the clients forehead
What is the end product of the metabolism of protein by the liver?
B.U.N
A client at risk for for continuing hyerkalemia states that she is upset because she cannot eat fruit every day. Which response by the nurse is best?
Berries, cherries, apples, peaches are low in potassium
A client has a history of hypothyroidsm. Which laboratory value is the nurse most concerned about?
Ca+ 8.2 mg/dl
What is the end product of muscle metabolism?
Creatinine
The nurse notes that the handgrip of the client with hypokalemiahas diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority ?
assess the clients, respiratory rate, depth and rhythm
Which question does nurse ask the client who has isotonic dehydration to determine a possible cause?
Do you take diuretics or water pills
A nurse is caring for a client who has a serum potassium 5.4, the nurse should assess for which of the following manifestations?
ECG changes
What fluid compartment comprises the intravascular, interstitial, and transcellular fluid contained?
Extracellular fluid compartment
The nurse assess distended neck veins in a client sitting in a chair to eat. What is the nurses priority intervention?
assess the pulse and blood pressure
A patient with mild fluid volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this patient? a) bumetanide b) torasemide c) hydrochlorothiazide d) furosemide
Hydrochlorothiazide
Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte imbalances?
I dont drink liquids after 5 PM so I dont have to get up at night
The nurse is providing discharge teaching. Which statement by the client indicates the need for further teaching regarding increased risk for metabolic alkalosis?
I take sodium bicarbonate after every meal to prevent heartburn
The nurse is instructing a patient with recurrent hyperkalemia about following a potassium restricted diet. Which statement indicates the need for additional instruction?
I will not salt my food, instead i'll use salt substitute
A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition?
I will weigh myself every morning before i eat or drink
A patient with a magnesium level of 2.6 mEq/L is being treated on a medical-surgical unit. Which of the following treatments should the nurse anticipate will be used?
IV furosemide (lasix)
What fluid compartment comprises fluid surrounding cells?
Interstitial space
What fluid compartment is the smallest compartment of the extracellular fluid space?
Interstitial space
What fluid compartment comprises about 60% of body fluid?
Intracellular space
What fluid compartment is third space fluid volume associated with?
Intravascular fluid volume defecit
What fluid compartment is the space where plasma is contained?
Intravascular space
Why does the administration of a 3% to 5% sodium chloride solution require intense monitoring?
It takes only a small amount to bring serum sodium levels up from dangerous levels
A client has metabolic alkalosis. Which lab results is the nurse most likely to assess as consistent with this condition?
K+ 3.1 mEq /L
A client has acute pancreatitis and a risk for acid-base imbalance. The nurse plans to assess for which manifestation consistent with this condition?
Kussmaul respirations
Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L?
measuring the urine output
The nurse is caring for a patient undergoing alcohol withdraw. Which of the following serum laboratory values should the nurse monitor closely?
Magnesium
A nurse is obtaining arterial blood gases for a client who has vomited for 24 hours, The nurse should expect which of the following acid base imbalances to result from vomiting for 24 hours?
Metabolic alkalosis
During assessment of hydration status, the client tells the nurse that she usually drinks 3 quarts of liquids each day. which question b the nurse is best?
What kinds of liquids do you usually drink?
Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client needs further assessment for fluid electrolyte imbalance ?
My rings seem to be tighter this week
What is the mathematical formula that a nurse would use to approximate the value of serum osmolality?
Na+ X 2= glucose/18 + BUN/3
What regulates the movement of water between the extracellular compartments? a) osmolality b) osmolarity c) osmosis d) diffusion
Osmolality
What senses changes in sodium concentrations?
Osmoreceptors
In the client with alkalosis, the nurse assesses for which clinical manifestations?
Positive Chvosteks sign, Positive Trousseaus sign, bradycardia
In clients with any type of acid-base imbalance, the nurse palces the priority on monitoring which electrolyte?
Potassium
What is the major positively charged ion intracellular fluid? a) sodium b) potassium c) plasma d) calcium
Potassium
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?
metabolic acidosis
In evaluating the electrocardiogram in a client with acidosis the nurse correlates which ecg change with effectiveness of therapy?
T-waves present, normal height
The nurse is caring for a patient with severe diarrhea. The nurse recognizes the patient is at risk for developing whcih of the following acid base imbalances?
metabolic acidosis
A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective?
metabolic acidosis can occur due to diabetic ketoacidosis
A client has a prolonged fever, for which acid-base imbalance does the nurse assess the client further?
metabolic acidosis from increased production of hydrogen ions
Which client statement indicates the need for more teaching regarding identification of the early manifestations of hypokalemia?
When i am constipated i drink more fluids
A client is being discharged with mild dehydration. Which statement by the client indicates an understanding of measures to prevent mild dehydration from becoming more severe?
When i feel lightheaded i will drink a full glass of water
A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective?
a chicken leg, one slice of bread with butter, steamed carrots
Which patient would a nurse assess most carefully for hyperkalemia?
a client with heart failure using a salt substitute
A patient has an arterial blood gas pH of 7.48. How does the nurse interpret this clients acid base status.
a deficit in blood hydrogen ion concentration
The nurse is reviewing the laboratory studies for a group of patients. which patient is most likely to experience a decrease in serum osmolality? a) a patient with diabetes insipidus b) a patient with a glucose level of 360 mg/dl c) a patient with kidney failure d) a patient with uremia
a patient with kidney failure
The nurse monitors for which acid-base problem in a client who is taking furosemide for hypertension?
acid deficit secondary to metabolic alkalosis
A client has been placed on a ventilator. The physician has ordered that the ventilator be set to deliver a respiratory rate of 28 breaths/minute. The nurse questions the order, citing concerns about which acid base problem?
acid deficit: alkalosis
The nurse notes that a patient's urine osmolality is 980 mOsm/kg. What should the nurse assess as a possible cause of this finding? a) acidosis b) fluid volume excess c) diabetes insipidus d) hyponatremia
acidosis
A client has been diagnosed with overhydration and is confused. Which intervention does the nurse include in the clients plan of care?
administering diuretic agents as prescribed
What factors contribute to hyponagnesemia?
alcohol abuse, diarrhea, gentamicin, untreated ketoacidosis
What factors contribute to hypokalemia?
alkalosis, vomiting, gastric suction, anorexia nervosa, hyperaldosteronism, lasix, steroid administration, penicillin
In a client 4 minutes post cardiac arrest the nurse correlates the largest source of excess hydrogen ions with which cause?
anaerobic metabolism leading to the build up of lactic acid
The nurse is caring for a patient with a metabolic acidosis (pH 7.25). Which of the following values is useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss?
anion gap
What monitors the bodies circulating volume and detects changes in pressure in the vessels?
barroreceptors
A client who is malnourished is being discharged. The nurse evaluates that teaching to decrease a risk for the development of metabolic acidosis has been effective when the client states, I will?
be sure to eat 3 well balanced meals and a snack daily
What is the most common buffer system in body?
bicarbonate-carbonic acid buffer system
Which ethnic groups should the nurse screen specifically for hypocalcemia?
blacks, asians, american indians
The nurse is caring for a patient who was admitted with fluid volume excess. What continuing assessment of this patient should the nurse include?
blood pressure, heart rate, and rhythm, intake and output, urine volume and color, and skin assessment for edema and turgor
The primary concentration of phosphorus (85%) is located in the _________ with about 15% located in ________________. a) bones b) plasma c) soft tissue d) 50
bones; soft tissues
How are calcium levels regulated?
by the parathyroid hormone and vitamin D
A patient reports tingling in the fingers as well as feeling depressed. The nurse assesses positive trousseau and chvostek signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned?
calcium
The nurse is caring for a patient with hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? a) red blood cell crenation b) red blood cell hydrolysis c) cerebral edema d) kidney injury
cerebral edema
A client is admitted with multiple fractures from a motor vehicle accident. Which of the clients previous or concurrent health problems is most likely to increase the clients risk for hypophophatemia?
chronic alcoholic pancreatitis
A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia?
client who is NPO receiving intravenous D5W
Which client is at greatest risk for developing hypercalcemia?
client with hyperparathyroidism
The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the for _______?
confusion
What are the symptoms of an air embolism which is a complication of intravenous therapy?
cyanosis, dyspnea, chest pain, hypotension, unresponsive, weak pulse
What would be some appropriate plans of care for a patient with fluid volume overload?
daily weight, listen for lung sounds, assess for leg edema
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. What would the nurse find as manifestations of fluid volume deficit?
decreased skin turgor, concentrated urine, low grade fever, tachypnea
The nurse reads in the medical record that a client has Kussmaul respirations. Which assessment finding is consistent with this condition?
deep rapid respirations
What would be a probable cause of respiratory alkalosis?
hypoxemia, gram negative bacterial infections
A client is being discharged and continues to be at risk for developing metabolic alkalosis. Which statement by the client indicates to the nurse that teaching has been effective?
i will avoid excess use of antacids
A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance?
diabetic ketoacidosis
The nurse is caring for a patient with a serum potassium level of 6.0 mEq/L. The patient is ordered to receive oral sodium polystyrene sulfonate (kayexelate) and furosemide (Lasix). What other orders should the nurse anticipate giving?
discontinuing the IV lactated ringers
What symptom would indicate to the nurse that there is a fluid volume deficit?
drop in postural blood pressure
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, weight gain of 2 lbs, and 1+ edema of the lower extremeties. The client has a temp of 99, pulse of 96/min, respirs of 26/min, O2 94% on 3 liters and blood pressure of 152/96. What manifestations of fluid volume excess should the nurse expext?
dyspnea, edema, hypertension, weakness
A nurse is assessing a client who has pancreatitis. The clients arterial blood gases reveal metabolic acidosis? Which of the following are expected findings?
dysrhythmia, tachypnea
When taking the blood pressure of a very ill client the nurse observes that clients hand undergoes flexion contractions. Which intervention is most appropriate?
ensure the client has a patent intravenous line
The nurse monitors for which acid base imbalance in a client who has hypoxemia?
excess carbon dioxide production leading to acidosis
The nurse is assessing a patient for local complication of IV therapy. Local complications include which of the following?
extravasation, hematoma, phlebitis
What foods can the nurse recommend for the patient with hypokalemia?
fruits such as bananas and apricots
What are some symptoms of fluid volume overload?
full bounding pulse, edema, neck vein distention
A client has been treated for hypokalemia. Which clinical manifestations or condition indicates that treatment has been effective?
having a bowel movement daily
A client in the emergency department has a potassium of 2.9 mEq/L . For which disease process or condition does the nurse assess the client?
hyperaldosteroneism
The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what potential complicatio?
hyperkalemia
What factors contribute to hypophosphatemia?
hyperparathyroidism, major thermal burns, alcohol withdrawal
What factors contribute to hypercalcemia?
hyperparthyroidism, malignant tumors, immobilization because of multiple fractures, thiazide diuretics
What occurs when the calcium-magnesium product exceeds 70 mg/dl?
hyperphosphatemia
What are the manifestations associated with an alteration in acid-base balance?
hypertension, lethargic, hypokalemia
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?
hypnatremia
The nurse is assigned to care for a patient with a serum phosphorus level of 5.0 mg/dl. The nurse anticipates that the patient will also experience which of the following electrolyte imbalances?
hypocalcemia
A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances?
hypokalemia
A client is in the emergency department after an overdose of an unknown substance. Which assessment findings does the nurse correlate with possible salicylate poisoning?
increased rate and depth of respiration
In a client with less than normal amount of bicarbonate in the blood and other extracellular fluids, what response does the nurse anticipate?
increased risk for acidosis
What are the three compartments that extracellular fluid is divided in to? (select all that apply) a) transmuscular b) intravascular c) transcellular d) interstitial
intravascular, transcellular, interstitial
When caring fora patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the priority for the nurse to follow up?
irregular heart rate
A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first?
just received 3 units of packed red blood cells
What factors contribute to hypermagnesemia?
kidney failure
What factors contribute to hyperphosphatemia?
kidney failure, neoplastic disease chemotherapy
What would be a probable cause of metabolic acidosis?
lactic acidosis, ketoacidosis, diarrhea
Which medication does the nurse anticipate administering for the patient with hypokalemia?
magnesium sulfate
Which action does the nurse teach a client to reduce the risk for dehydration?
maintaining a daily oral intake approximately equal to daily fluid loss
What is the primary complication on hyperphosphatemia?
metastatic calcification of soft tissue, joints, and arteries
A nurse is caring for an older adult client in a long term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. The clients temp is 100.9, pulse is 92, respirations 20/min and blood pressure 108/60 mm Hg. He has 3/4 pounds and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. What actions should the nurse take?
monitor for orthostatic hypotension
Sodium establishes the electrochemical state necessary for _______________, and _________________. a) muscle tone b) muscle contraction c) tonicity d) nerve impulse transmission
muscle contraction; nerve impulse transmission
A client with chronic respiratory acidosis is receiving oxygen by nasal cannula at 6 liters/min. The clients respiratory rate is 8 breaths per minute. Which action by the nurse is the priority?
notify the rapid response team and prepare for intubation
What intervention is most important to teach the client about identifying the onset of dehydration?
obtaining and charting daily weight
Which client is at greatest risk for dehydration?
older adult client with cognitive impairment
A patient has been involved in a a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestation? (select all that apply) a) hypertension b) oliguria c) tachycardia d) bradycardia e) tachypnea
oliguria, tachycardia, tachypnea
The nurse assesses the client with which condition most carefully for the risk of developing acute respiratory acidosis?
on patient controlled analgesia after abdominal surgery
A patient with abnormal sodium losses is receiving a regular diet. How can the nurse supplement the patient's diet to provide 1600 mg of sodium daily? a) one beef cube and 8 oz of tomato juice b) four beef cubes and 8 oz of tomato juice c) one beef cube and 16 oz of tomato juice d) one beef cube and 12 oz of tomato juice
one beef cube and 8 oz of tomato juice
What nursing intervention would the nurse do to help indicate there is a fluid volume deficit?
orthostatic vital signs
Pressure exerted by proteins, needed to stop the flow of water by osmosis.
osmotic pressure
The nurse is analyzing the arterial blood gas results of a patient diagnosed with severe pneumonia. What ABG result indicates respiratory acidosis?
pH 7.20, PaCO2 65 mm Hg, HCO3 26 mEq/L
The nurse interprets which arterial blood gas values as partially compensated metabolic acidosis?
pH 7.32, HCO3 17 mEq, PCO2 25 mmHg, PO2 98 mmhg
A client has a calcium of 14 mg/dl. Which intervention is the priority?
placing the client on a cardiac monitor
A client is on a potassium restricted diet. which protein choice by the client indicates a good understanding of the dietary regimen?
poached eggs
A client has the following laboratory Ca+ 8.7 mg/dL; K+ 4.2 mEq/l; Na+ 142 mEq/l. Which intervention by the nurse is most appropriate?
prepare to administer aluminum hydroxide
A patient is being treated in the ICU 24 hours after having a radical neck dissection completed. The patient's serum calcium level is 7.6 mg/dl. Which of the following phsysical examination findings is consistent with this electrolyte imbalance?
presence of trousseaus sign
The nurse is analyzing the ECG rhythm tracing of a patient experiencing hypercalcemia. Which of the following ECG changes is typically assoicated with this electrolyte imbalance?
prolonged PR intervals
A nurse is caring for a patient with acute renal failure and hypernatremia. Which of the following actions can be delegated to the nursing assistant?
provide oral care every 2-3 hours
A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy?
pulse rate of 115 beats per minute
A client has been NPO after a colectomy with nasogastric suction in place. On assessment the nurse finds the client reporting cramps in the calves. Which action by the nurse is most appropriate?
raise the side rails and notify the physician
What manifestation of extracellular fluid volume excess would a nurse anticipate finding?
rapid weight gain
The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia. What action is most important for the nurse to teach the client?
read the food labels to determine the sodium content
When a client has an arterial blood pH of 7.48 which buffer action will bring the pH back to normal?
release of hydrogen ions into the blood
A client has mild acidosis but after a day has not compensated for it. Which action by the nurse is best?
review the clients daily hemoglobin and hematocrit
A client has sever metabolic alkalosis. Which nursing diagnosis does the nurse choose as the clients priority problem.?
risk for injury related to increased neuronal sensitivity from hypocalcemia
A client has been taught to increase potassium in the diet. what dietary meal selection indicates to the nurse that teaching has been effective>
sausage, one slice of whole wheat toast, and a cup of strawberries
The nurse is participating in the care of a patient who had a PICC line placed in the right arm. Following catheter palcement, the nurse should complete which of the following actions?
send the patient for a chest xray
The nurse is reviewing the lab studies for a patient suspected of acute kidney injury. What test would be the best indicator of the patient's renal function? a) blood urea nitrogen b) serum creatinine c) specific gravity d) urine osmolality
serum cratinine
Sodium is regulated by what 3 components? (select all that apply) a) osmotic pressure b) thirst c) tetany d) ADH e) renin-angiotensin aldosterone
thirst; ADH; renin-angiotensin aldosterone
A nurse is caring for a client who has a serum sodium level 133and serum potassium level 3.4. The nurse should recognize that which of the following treatments can result in these laboratory findings?
three tap water enemas
What factors contribute to hyperkalemia?
tourniquet too tight when collecting a blood sample, leukocytosis, kidney failure, adrenal steroid deficiency
What measures the kidneys ability to excrete or conserve water?
urine specific gravity
A client has a history of hypocalcemia. What intervention is most important for the nurse to add to this clients care plan?
use nonslip footwear to get out of bed
What factors contribute to hyponatremia?
vomiting, diarrhea, diuretics, adrenal insufficiency, syndrome of inappropriate antiduretic hormone, excessive parental administration of dextrose and water solution
What would be a probable cause of metabolic alkalosis?
vomiting, hypokalemia
What factors contribute to hypernatremia?
watery diarrhea, inability to quench thirst, burns over a large surface area, heat stroke, status post therapeutic abortion, diabetes insipidus with water restriction
Which client does the nurse assess for potential metabolic acidosis?
young adult following a carbohydrate free diet
Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion?
applying oxygen by mask or nasal cannula
The hand grasps of a client with acidosis have diminished since the previous assessment 1 hour ago. what action does the nurse take?
asses the clients rate, rhythm, and depth of respiraton
The nurse observes that the handgrip of the client with hypophosphatemia has diminished in strength since the last assessment 2 hours ago. What is the nurses primary intervention?
assess respiratory status immediately
A client has moderate metabolic alkalosis. What is the priority intervention for the nurse?
assess the clients muscle strength
The nurse is caring for a patient with a diagnosis of hyponatremia. What nursing intervention is appropriate to include in the plan of care for this patient? (select all that apply) a) assessing for symptoms of nausea and malaise b) encouraging the intake of low-sodium liquids c) monitoring neurologic status d) restricting tap water intake e) encouraging the use of salt substitute instead of salt
assessing for symptoms of nausea and malaise, monitoring neurologic status, restricting tap water intake
A client is being discharged and needs to self-monitor for the development of hyperkalemia. which intervention is most important for the nurse to teach the client?
assessing radial pulse for a full minute twice a day
What laboratory findings does the nurse determine are consistent with hypovolemia in a female patient? ( select all that apply) a) hematocrit level of >47% b) BUN: serum creatinine ratio of >12.1 c) urine specific gravity of 1.027 d) urine osmolality of >450 mOsm/kg e) urine positive for blood
hematocrit level of >47%, urine specific gravity of 1.027, urine osmoloality of >450 mOsm/kg
The nurse expects to find renal compensation for an acid base imbalance in which situation?
hypoxemia for 4 days from pneumonia in an adult woman
Which response is an example of compensation for an acid-base imbalance?
increase in the rate and depth of respirations when exercising
In the client with hypoventilation which change in arterial blood gases does the nurse evaluate to determine whether treatment measures are being effective?
increased arterial blood bicarbonate
A postopertive client received 6 units of packed red blood cells for inraoperative blood loss. The nurse monitors the client for which acid-base imbalance?
metabolic alkalosis
A nurse is assessing a client for chvotesks sign. Which of the following techniques should the nurse use to perform this test?
tap lightly on the clients cheek
What would be the appropriate nursing interventions for a patient with fluid volume deficit?
reposition, measure urine output, elevate the legs, prevent postural hypotension
A client is being discharged from the ED with several broken ribs. For which acid base imbalance does the nurse provide discharge teaching?
respiratory acidosis from inadequate ventilation
What would be a probable cause of respiratory acidosis?
sedative overdose, severe pneumonia, acute pulmonary edema
A client with hypophosphatemia is being discharged. Which activity demonstrated by he client indicates that discharge teaching has been effective?
selecting foods high in phosphorus and low in calcium
The nurse assesses for acidosis in the client with which assessment data?
serum potassium level of 6.5 mEq per liter and flaccid paralysis
What abundant electrolyte is primarily responsible for maintaining fluid osmolality? a) potassium b) calcium c) sodium d) phosphorus
sodium
What is the major positively charged ion in extracellular fluid? a) potassium b) calcium c) sodium d) chloride
sodium
The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 ml solution of dextrose 5% in 0.45% saline. The client states hat the area around the IV site burns. What intervention does the nurse perform first?
stop the IV infusion
A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client?
tachycardia
The nurse is caring for a patient diagnosed with hypercholeremia. Signs and symptoms of hypercholeremia include?
tachypnea, weakness, lethargy
A client has moderate acidosis, which assessment does the nurse perform first?
take the clients pulse and blood pressure and analyze the ECG strip
