Chapter 16 Fluid and electrolytes
The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? A)Intracellular fluid B)Extracellular fluid C)Interstitial fluid D)Intravascular fluid
Ans: A Feedback: About 60% of the adult human body is water. Most body water is located within the cell (intracellular fluid). Due to several physiological changes of aging, geriatric clients have less bodily fluids.
The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? A) Potassium: 5.8 mEq/L B) Sodium: 138 mEq/L C) Magnesium: 2 mEq/L D) Calcium: 10 mg/dL
Ans: A Feedback: Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.
The nursing instructor is talking with her junior nursing class about fluid and electrolyte balance. What would the instructor tell her students that the average daily fluid intake for an adult is? A)2000 mL B)2500 mL C)3000 mL D)3500 mL
Ans: B Feedback: In healthy adults, oral fluid intake averages about 2500 mL/day; however, it can range between 1800 and 3000 mL/day, with a similar volume of fluid loss.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? A)Low heart rate B)Elevated blood pressure C)Rapid respiration D)Subnormal temperature
Ans: B Feedback: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? A)Similar causes are present in both conditions. B)Hypovolemia contains only low blood volume. C)In dehydration, only extracellular is depleted. D)Both conditions result in abnormal laboratory studies.
Ans: C Feedback: In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.
. The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the rise in pH? A)The lungs are unable to breathe in sufficient oxygen. B)The lungs are unable to exchange oxygen and carbon dioxide. C)The lungs have ineffective cilia from years of smoking. D)The lungs are not able to blow off carbon dioxide.
Ans: D Feedback: In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, it is the lungs ability to remove the carbon dioxide from the system. Although individuals with COPD frequently have a history of smoking, cilia is not the cause of the acidosis.
Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30 mm Hg; and HCO3, 21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state? A)Compensated respiratory alkalosis B)Uncompensated respiratory alkalosis C)Compensated metabolic acidosis D)Compensated metabolic alkalosis
Ans: A Feedback: The question states that the client has a history of acid-base disturbance. The nurse would first note that the pH has returned to close to normal indicating compensation. The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3 (normal: 22 to 27 mEq/L) levels. In a respiratory condition, the pH and the PCO2 move in opposite direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low, also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).
The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression? A)Decreased abdominal girth B)Increased level of consciousness C)Weight maintenance D)Pulse rate decrease
Ans: A Feedback: Third-spacing is the translocation of fluid from the intravascular to intercellular space to tissue compartment. Anasarca is the general edema in the organ cavities such as the abdomen. Monitoring the abdominal girth provides data on the localization of the fluid in the interstitial space. A decrease in girth, in particular, notes improvement. Level of consciousness is not affected unless shock occurs. Weight remains the same as there is a shifting in fluid; pulse rate could fluctuate according to fluid movement.
You are caring for a client with severe hypokalemia. The physician has ordered IV potassium to be administered at10 mEq/hr. The client complains of burning along his vein. What should you do? A)Seek a physician's order to dilute the infusion. B)Switch to an oral formulation. C)Increase the speed of transfusion. D)Change the electrolyte.
Ans: A Feedback: Treatment of severe hypokalemia requires treatment with IV infusion of potassium. Clients may experience burning along the vein with IV infusion of potassium in proportion to the infusion's concentration. If the client can tolerate the fluid, consult with the physician about diluting the potassium in a larger volume of IV solution. Oral potassium may not be enough in severe cases hypokalemia. Hypokalemia requires treatment with potassium and not any other electrolyte.
The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. A)An elevated hematocrit level B)A low urine specific gravity C)Electrolyte imbalance D)Low protein level in the urine E)Absence of ketones in urine
Ans: A, C Feedback: Dehydration is a common primary or secondary diagnosis in healthcare. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.
A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and his family? Select all that apply. A)Drink at least eight glasses of fluid each day. B)Drink caffeinated beverages to retain fluid. C)Drink carbonated beverages to help balance fluid volume. D)Drink water as an inexpensive way to meet fluid needs. E)Respond to thirst.
Ans: A, D, E Feedback: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits
The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a class of sixth graders. Which action by bases keeps the blood pH nearly neutral? A)Bases cast off acids. B)Bases bind with hydrogen. C)Bases hold acidic properties. D)Bases have no contact with acids.
Ans: B Feedback: Acids are substances that release hydrogen into fluid, bases are substances that bind with hydrogen. The delicate balance between acids and bases, as well as fluids and electrolytes, maintains the nearly neutral blood pH.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur? A)Respiratory alkalosis B)Metabolic alkalosis C)Respiratory acidosis D)Metabolic acidosis
Ans: B Feedback: Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.
The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis? A)A blood pressure elevation upon rising or activity B)A drop in systolic blood pressure (15 mmHg) upon rising C)A pulsating headache D)A drop in diastolic blood pressure (25 mm Hg) upon rising
Ans: B Feedback: Postural hypotension occurs when the client rises from a supine or semi-Fowler's position to a standing position and the systolic blood pressure drops by 15 mm Hg. The client has symptoms of dizziness or a near syncopal episode.
Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing? A)Initiate an IV of an isotonic solution. B)Initiate an IV of albumin. C)Manage an infusion of plasma. D)Manage an infusion of total parenteral nutrition.
Ans: B Feedback: The best answer to restore colloidal osmotic pressure is to initiate an IV of albumin. Administration of albumin pulls the trapped fluid back into the intravascular space. An isotonic solution will not pull water from the intercellular space. Blood products are used for third-spacing management; however, albumin is the product of choice. The management of total parenteral nutrition is not associated with third-spacing.
A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid? A)Isotonic fluid B)No intravenous solution C)Hypertonic solution D)Hypotonic solution
Ans: B Feedback: There are three types (tonicity) of intravenous fluids, which are isotonic, hypotonic, and hypertonic solutions. By process of osmosis and diffusion, solutes are moved through the body. A hypertonic solution is used to pull water back in to circulation as a hypertonic solution has more particles than the body's water. An isotonic solution is the same concentration as the body's water and is used as an intravenous volume expander. A hypotonic solution has fewer particles than the body's water thus shifting water from the vascular space to the tissue.
The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? A)Endocrine system B)Gastrointestinal system C)Neurological system D)Musculoskeletal system
Ans: C Feedback: A client with a calcium level of 4.0 mg/dL has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A) A 7-year-old with a fracture tibia B) A 65-year-old with a myocardial infarction C) A 52-year-old with diarrhea D) A 72-year-old with a total knee repair
Ans: C Feedback: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic patients will not likely have an electrolyte imbalance. Myocardial infarction patients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a client favorite, will the nurse discourage? A)A grilled chicken sandwich with mayonnaise B)A natural fruit salad with nuts C)A hot dog with catsup D)A fresh grilled tuna entrée with fresh asparagus
Ans: C Feedback: Foods high in sodium include processed meats, such as hot dogs and cold cuts; fast foods; frozen meals; cheeses; soups and juices; and salted snack foods to name a few.
You are caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition? A)Dehydration B)Hypokalemia C)Hypocalcemia D)Hypomagnesemia
Ans: C Feedback: Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding.
Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia? A)Hypervolemia B)Hypercalcemia C)Hypomagnesemia D)Hypermagnesemia
Ans: C Feedback: If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia.
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? A)Kidney and liver B)Heart and lungs C)Lungs and kidney D)Pancreas and stomach
Ans: C Feedback: The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.
The nurse receives report that a client's pH level is 7.4. Which nursing action would be most appropriate? A)Call the physician with the report. B)Encourage the client to deep breath. C)Complete a head-to-toe assessment. D)Obtain an ECG.
Ans: C Feedback: The nurse realizes that a pH level of 7.4 is within normal limits. No additional measures need obtained and the nurse would perform a usual head-to-toe assessment.
What is one process by which dissolved chemicals from one area of the body to another? A)Passive osmosis B)Free flow C)Passive elimination D)Active transport
Ans: D Feedback: Active transport requires an energy source, a substance called adenosine triphosphate (ATP), to drive dissolved chemicals from an area of low concentration to an area of higher concentration—the opposite of passive diffusion.
The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)? A)Osmosis B)Passive diffusion C)Facilitated diffusion D)Active transport
Ans: D Feedback: Active transport requires the use of the body's energy molecule (ATP) to meet body needs for fluid and particle transport. Osmosis is the movement of body fluids through a semipermeable membrane that allows not all substances to pass through. Passive diffusion allows the movement of substances from an area of higher concentration to lower concentration. Facilitated diffusion has certain dissolved substances that require the assistance from a carrier module to pass through the semipermeable membrane.
The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? A)PaO2 B)PO2 C)Carbonic acid D)Bicarbonate
Ans: D Feedback: Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.
The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status? A)Vital signs B)Edema C)Intake and output D)Weight
Ans: D Feedback: Daily weight provides the ability to monitor fluid status. A 2-lb weight gain in 24 hours indicates that the client is retaining 1 L of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output don't account for insensible fluid loss.
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? A)Cool and pale skin B)Crackles in the lung fields C)Distended jugular veins D)Dark, concentrated urine
Ans: D Feedback: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.
The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? A)Lung function B)Summer allergies C)Cardiovascular compromise D)Insensible fluid loss
Ans: D Feedback: Due to the high heat and humidity, geriatric clients are at a high risk for insensible fluid loss through perspiration and vapor in the exhaled air. These losses are noted as unnoticeable and unmeasurable. Those with respiratory deficits and allergies may be only able to be outside for a limited period. Those with cardiovascular compromise may need to alternate outdoor activities with indoor rest.
The nurse is providing nutritional instruction to the client diagnosed with hypovolemia. Which would the nurse emphasize as something to avoid? A)Eight to 10 glasses of water per day B)Foods high in sodium C)Potassium-rich fruit D)Beverages with alcohol or caffeine
Ans: D Feedback: The nursing management of clients with hypovolemia is to restore fluid balance. The nurse provides nutritional information and instructs the client to avoid beverages with alcohol and caffeine, which increases urination and contributes to the fluid deficits. The clients should drink 8 to 10 glasses of water daily, include sodium in the diet, and eat potassium-rich fruit.
A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? A)Yes, this will correct the sodium deficit. B)Yes, along with the hypotonic IV. C)No, start with the sodium chloride IV. D)No, sodium intake should be restricted.
Ans: D Feedback: The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.
The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance? A)Suggest a fluid restriction. B)Encourage oral fluids. C)Remove the Hemovac. D)Offer a prescribed antiemetic medication.
Ans: D Feedback: When calculating the intake and output of a client, it is essential to understand that the normal average intake is 2500 mL in adults. Ranges are often noted at 1800 to 3000 mL. Because the client is vomiting, offering a prescribed antiemetic medication would decrease the output from emesis and increase the input as the client may be more accepting of oral fluids. The client should be encouraged more oral intake once vomiting has subsided, but if not possible, intravenous fluids should be increased to avoid dehydration. A fluid restriction could cause dehydration. Removing the Hemovac will decrease documented output but may lead to an internal infection from fluid accumulation.
A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client? A)Slow heart rate B)Kidney stones and blood clots C)Imbalance in electrolytes D)Elevated central venous pressure (CVP)
Ans: B Feedback: Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high because the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below 4 cm H2O.
Your clients lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap? A)Metabolic acidosis B)Respiratory alkalosis C)Metabolic alkalosis D)Respiratory acidosis
Ans: A Feedback: The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) - (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? A)Abnormal potassium level B)Elevated hematocrit level C)Low white blood count D)Low urine specific gravity
Ans: B Feedback: When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.
