Chapter 13
A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering? a) 0.45% NaCl b) Lactated Ringer's solution c) 0.9% NaCl d) 5% NaCl
a) 0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer's solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.
The nurse has been assigned to care for the following patients. Which patient is at the highest risk for a fluid and electrolyte imbalance? a) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). b) A 45-year-old man who had a laparoscopic appendectomy 24 hours ago being advanced to a regular diet. c) A 66-year-old woman who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift. d) A 79-year-old man admitted with a diagnosis of pneumonia.
a) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). Explanation: The 82-year-old patient has three risk factors: advanced age, tube feedings, and diuretic usage (Demadex). This patient has the highest risk for fluid and electrolyte imbalances. The 45-year-old man has the risk factor of surgery but is not the patient at the highest risk. The 79-year-old patient has the risk factor of advanced age but is not the patient at the highest risk. The 66-year-old patient has the risk factors of age and the bile drain but is not the patient at the highest risk.
The nurse is caring for a patient who was admitted with fluid volume excess (FVE). Which of the following nursing assessments should the nurse include in the ongoing monitoring of the patient? Select all that apply. a) Blood pressure, heart rate, and rhythm b) Intake and output, urine volume, and color c) Strength testing for muscle wasting d) Skin assessment for edema and turgor e) Nutritional status and diet
a) Blood pressure, heart rate, and rhythm, b) Intake and output, urine volume, and color, d) Skin assessment for edema and turgor Explanation: To assess for FVE the nurse measures: blood pressure, heart rate and rhythm, breath sounds, skin assessment for edema and turgor, inspection of neck veins, intake and output, daily weights, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess.
The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following? a) Confusion b) Headache c) Hallucinations d) Nausea
a) Confusion Explanation: Normal serum concentration level ranges from 135 to 145 mEq/L. Hyponatremia exists when the serum level decreases below 135 mEq/L, there is. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium levels.
The nurse is assessing a patient for local complication of IV therapy. Local complications include which of the following? Select all that apply. a) Extravasation b) Infection c) Air embolism d) Hematoma e) Phlebitis
a) Extravasation, d) Hematoma, e) Phlebitis Explanation: Local complications of IV therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, febrile reaction, and infection.
The nurse is caring for a patient diagnosed with hyperchloremia. Signs and symptoms of hyperchloremia include which of the following? Select all that apply. a) Weakness b) Lethargy c) Hypotension d) Dehydration e) Tachypnea
a) Weakness, b) Lethargy, e) Tachypnea Explanation: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention.
The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, 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 which of the following? a) 145 mEq/L b) 155 mEq/L c) 125 mEq/L d) 135 mEq/L
b) 155 mEq/L Explanation: The patient is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.
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? a) Change the lactated Ringer's solution to 3% saline. b) Discontinue the IV lactated Ringer's solution. c) Increase the rate of the IV lactated Ringer's solution. d) Change the lactated Ringer's solution to 2.5% dextrose.
b) Discontinue the IV lactated Ringer's solution. Explanation: The lactated Ringer's IV fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer's contains more sodium than daily requirements and excess sodium worsens fluid volume excess. Lactated Ringer's also contains potassium, which would worsen the hyperkalemia.
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? a) Hyperchloremia b) Hypocalcemia c) Hyponatremia d) Hypermagnesemia
b) Hypocalcemia Explanation: The patient is experiencing an elevated serum phosphorus level. Hyperphosphatemia is defined as a serum phosphorus level that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus level tends to cause a low serum calcium concentration.
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? a) Hypocalcemia b) Hypokalemia c) Hyponatremia d) Hypomagnesium
b) Hypokalemia Explanation: Potassium-losing diuretics, such as the thiazides and loop diuretics, can induce hypokalemia. Gastrointestinal (GI) loss of potassium is another common cause of potassium depletion. Vomiting and gastric suction frequently lead to hypokalemia.
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? a) Fluid restriction b) IV furosemide (Lasix) c) Dialysis d) Oral magnesium oxide (MagOx)
b) IV furosemide (Lasix) Explanation: The nurse should anticipate the administration of Lasix for the treatment of hypermagnesemia. Administration of loop diuretics (e.g., furosemide) and sodium chloride or lactated Ringer's IV solution enhances magnesium excretion in patients with adequate renal function. Fluid restriction is contraindicated. The patient should be encouraged to increase fluids to promote the excretion magnesium by way of the urine. MagOx is contraindicated as it would further elevate the patient's serum magnesium level. In acute emergencies, when the magnesium level is severely elevated, hemodialysis with a magnesium-free dialysate can reduce the serum magnesium to a safe level within hours.
The nurse is caring for a patient with severe diarrhea. The nurse recognizes that the patient is at-risk for developing which of the following acid-base imbalances? a) Respiratory alkalosis b) Metabolic acidosis c) Respiratory acidosis d) Metabolic alkalosis
b) Metabolic acidosis Explanation: The patient is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
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 physical examination findings is consistent with this electrolyte imbalance? a) Slurred speech b) Presence of Trousseau's sign c) Muscle weakness d) Negative Chvostek's sign
b) Presence of Trousseau's sign Explanation: A patient status post radical neck resection is prone to developing hypocalcemia. Hypocalcemia is defined as a serum values lower than 8.6 mg/dL [2.15 mmol/L]. Signs and symptoms of hypocalcemia include: Chvostek's sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped, and a positive Trousseau's sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.
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? a) Teach the patient about increased fluid intake. b) Provide oral care every 2-3 hours. c) Assess the patient's daily weights for trends. d) Monitor for signs and symptoms of dehydration.
b) Provide oral care every 2-3 hours. Explanation: Providing oral care for the patient every 23 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.
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 laboratory finding, the nurse should suspect which of the following statements? a) The patient has a history of alcohol abuse. b) The patient's malignancy is causing the electrolyte imbalance. c) The patient may be developing hyperaldosteronism. d) The patient's diet is lacking in calcium-rich food products.
b) The patient's malignancy is causing the electrolyte imbalance. Explanation: The patient's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium level greater than 10.2 mg/dL (2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia by a variety of mechanisms. The patient's calcium level is elevated; there is no indication that the patient's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.
The nurse is instructing a patient with recurrent hyperkalemia about following a potassium-restricted diet. Which of the following patient statements indicates the need for additional instruction? a) "Bananas have a lot of potassium in them, I'll stop buying them." b) "I'll drink cranberry juice with my breakfast instead of coffee." c) "I will not salt my food, instead I'll use salt substitute." d) "I need to check if my cola beverage has potassium in it."
c) "I will not salt my food, instead I'll use salt substitute." Explanation: The patient should avoid salt substitutes. The nurse must caution patients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.
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? a) PaCO2 b) Serum sodium level c) Anion gap d) Bicarbonate level
c) Anion gap Explanation: Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.
When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? a) Blood pressure 96/53 mm Hg b) Mild confusion c) Irregular heart rate d) Weight loss of 4 lb
c) Irregular heart rate Explanation: Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, but following up on potential cardiac dysrhythmias is a higher priority. Confusion may occur with dehydration and hyponatremia, but following up on potential cardiac dysrhythmias is a higher priority. The blood pressure is slightly lower than normal but is not life threatening. Following up on potential cardiac dysrhythmias is a higher priority.
The nurse is caring for a patient undergoing alcohol withdrawal. Which of the following serum laboratory values should the nurse monitor most closely? a) Calcium b) Potassium c) Magnesium d) Phosphorus
c) Magnesium Explanation: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium level should be measured at least every 2 or 3 days in patients undergoing alcohol withdrawal. The serum magnesium level may be normal on admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with IV glucose administration
The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a patient experiencing hypercalcemia. Which of the following ECG changes is typically associated with this electrolyte imbalance? a) Elevated ST segments b) Peaked T waves c) Prolonged PR intervals d) Prolonged QT intervals
c) Prolonged PR intervals Explanation: Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium level.
The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? a) pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L b) pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L c) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L d) pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L
c) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3- : 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3- : 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3- : 22 mEq/L indicate a normal result/no imbalance.
Which of the following arterial blood gas (ABG) results would the nurse anticipate for a patient with a 3-day history of vomiting? a) pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 b) pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 c) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 d) pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15
c) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The patient's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium level of 2.9 mEq/L. Which of the following statements made by the patient indicates the need for further teaching? a) "I will take a potassium supplement daily as prescribed." b) "I will be sure to buy frozen vegetables when I grocery shop." c) "A good breakfast for me will include milk and a couple of bananas." d) "I can use laxatives and enemas but only once a week."
d) "I can use laxatives and enemas but only once a week." Explanation: The patient is experiencing hypokalemia most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum K+ level below 3.5 mEq/L [3.5 mmol/L], and usually indicates a deficit in total potassium stores. Patients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting, misuse of laxatives, diuretics, and enemas; thus, the patient should avoid laxatives and enemas. Prevention measures may involve encouraging the patient at risk to eat foods rich in potassium (when the diet allows) including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, patient education may help alleviate the problem.
A patient presents to the Emergency Department experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient's pH value to be which of the following? a) 7.35 b) 7.30 c) 7.45 d) 7.50
d) 7.50 Explanation: The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, Gram-negative bacteremia, and inappropriate ventilator settings.
The nurse is participating in the care of a patient who had a peripherally inserted central catheter (PICC) inserted in the right arm. Following catheter placement, the nurse should complete which of the following actions? a) Administer the prescribed IV fluids. b) Assess the patient's blood pressure (BP) on the right arm. c) Obtain written consent for the procedure. d) Send the patient for a chest x-ray.
d) Send the patient for a chest x-ray. Explanation: A chest x-ray is needed to confirm the placement of catheter tip prior to initiation of ordered infusion. Consent should be obtained prior to the procedure, not after the procedure. No BPs should be taken on the extremity where the catheter is placed.