Chapter 16-fluid, electrolyte, and acid-base imbalances

the nurse is caring for a patient with a massive burn injury and possible hypovolemia. which assessment data will be of most concern to the nurse? a. BP is 90/40 mm Hg. b. urine output is 30 mL over the last hour c. oral fluid intake is 100 mL for the last 8 hours d. there is prolonged skin tenting over the sternum.

a. BP is 90/40 mm Hg. the BP indicates that the pt may be developing hypovolemic shock as a result of intravascular fluid loss d/t the burn injury. this finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. the poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the pts fluid intake but not as urgently as the hypotension.

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives

a. Daily alcohol intake hypomagnesemia is associated with alcoholism. protein intake would not have a significant effect on magnesium level. OTC laxatives and use of multivitamin/mineral supps would tend to increase magnesium levels.

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

a. Monitor ionized calcium level. this pt with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. a more accurate reflection of calcium balance is the ionized calcium level. most of the calcium in the blood is bound to protein. alterations in serum albumin levels affect the interpretation of total calcium levels. low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. the other actions may be needed if the ionized calcium is also decreased.

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing

a. Presence of the Chvostek's sign the pts symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. there is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

a. The patient is experiencing laryngeal stridor. hypocalcemia can cause laryngeal stridor, which may lead to resp arrest. rapid action is required to correct the pts calcium level. the other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm

a newly admitted pt is diagnosed with hyponatremia. when making room assignments, the charge nurse should take which action? a. assign the pt to a room near the nurses station b. place the pt in a room nearest to the water fountain c. place the pt on telemetry to monitor for peaked T waves d. assign the pt to a semi-private room and place an order for a low-salt diet.

a. assign the pt to a room near the nurses station the pt should be placed near the nurses station if confused in order for the staff to closely monitor the pt. to help improve serum sodium levels, water intake is restricted. therefore a confused pt should not be placed near a water fountain. peaked T waves are a sign of hyperkalemia, not hyponatremia. a confused pt could be distracting and disruptive for another pt in a semi-private room. this pt needs sodium replacement, not restriction.

the HH nurse cares for an alert and oriented older adult pt with a history of dehydration. which instructions should the nurse give to this pt related to fluid intake? a. increase fluids if your mouth feels dry b. more fluids are needed if you feel thirsty c. drink more fluids in the late evening hours d. if you feel lethargic or confused, you need more to drink

a. increase fluids if your mouth feels dry an alert, older pt will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. the thirst mechanism decreases with age and is not an accurate indicator of volume depletion. many older pts prefer to restrict fluids sightly in the evening to improve sleep quality. the pt will not be likely to notice and act appropriately when changes in LOC occur.

a post-op pt who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. the pt now has a serum sodium level of 127 mEq/L. which prescribed therapy should the nurse question? a. infuse 5% dextrose in water at 125 mL/hr b. administer IV morphine sulfate 4 mg every 2 hours PRN c. give IV metoclopramide (reglan) 10 mg every 6 hours PRN for nausea d. administer 3 % saline if serum sodium decreased to less than 128 mEq/L

a. infuse 5% dextrose in water at 125 mL/hr because the pts gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. solutions such as lactated ringers solution would usually be ordered for this pt. the other orders are appropriate for a postop pt with a gastric suction.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

a. lung sounds. hypertonic solutions cause water retention, so the pt should be monitored for symptoms of fluid excess. crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute resp or cardiac decompensation

a patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. how should the nurse interpret these results? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

a. metabolic acidosis the pH and HCO3 indicate that the pt has a metabolic acidosis. the ABGs are inconsistent with the other responses.

a pt with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (maalox) at home for indigestion. the pt arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. which action should the dialysis nurse take FIRST? a. notify the pts HCP b. obtain an order to draw a potassium level c. review the magnesium level on the pts chart d. teach the pt about the risk of magnesium-containing antacids.

a. notify the pts HCP the HCP should be notified immediately. the pt has a hx and manifestations consistent with hypermagnesemia. the nurse should check the hart for a recent serum mag level and make sure that blood is sent to the lab for immediate electrolyte and chem determinations. dialysis should correct the high mag levels. the pt needs teaching about the risks of taking mag-containing antacids. monitoring of potassium levels also is important for pts with renal failure, but the pts current symptoms aren ot consistent with hyperkalemia.

a patient who has been receiving diuretic therapy is admitted to the ED with a serum potassium level of 3.0 mEq/L. the nurse should alert the HCP immediately that the pt is on which medication? a. oral digoxin (lanoxin) 0.25 mg daily b. Ibuprofen (motrin) 400 mg every 6 hours c. metoprolol (lopressor) 12.5 mg orally daily d. lantus insulin 24 U subcut every evening.

a. oral digoxin (lanoxin) 0.25 mg daily hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. the nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.

b. Infuse the KCl at a rate of 10 mEq/hour. IV KCl is administered at a max rate of 10 mEq/hr. rapid IV infusion of KCl can cause cardiac arrest. although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 may be used for some pts. KCl can cause inflammation of peripheral veins, but it can be administered by this route. cardiac monitoring should be continued while pt is receiving potassium because of the risk of dysrhythmias.

a pt comes to the clinic complaining of frequent, watery stools for the last 2 days. which action should the nurse take first? a. obtain the baseline weight b. check the pts BP c. draw blood serum electrolyte levels d. ask about any extremity numbness or tingling

b. check the pts BP because the pts hx suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. the other actions are also appropriate, but are not as essential as determining the pts perfusion status.

a pt is admitted for hypovalemia associated with multiple draining wounds. which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. skin turgor b. daily weight c. presence of edema d. hourly urine output

b. daily weight daily weight is the most easily obtained and accurate means of assessing volume status. skin turgor varies considerably with age. considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. although very important, hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the GI tract or wounds.

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema c. Confusion d. Restlessness

b. edema the normal range for total protein is 6.4 to 8.3 g/dL. low serum protein levels cause a decrease in placma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. confusion, restlessntess, and pallor are not associated with low serum protein levels.

a patient who had a transverse colectomy for diverticulosis 18 hours ago has a nasogastric suction and is complaining of anxiety and incisional pain. the pts resp rate is 32 and the arterial blood gases indicate resp alkalosis. which action should the nurse take first? a. discontinue the nasogastric suction b. give the pt the PRN IV morphine sulfate 4 mg c. notify the HCP about the ABG results d. teach the pt how to take slow, deep breaths when anxious

b. give the pt the PRN IV morphine sulfate 4 mg the pts resp alkalosis is caused by the increased resp rate associated with pain and anxiety. the nurses first action should be to medicate the pt for pain. although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube with the pt needs gastric suction. the HCP may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. the pt will not be able to take slow, deep breaths when experiencing pain.

when caring for a pt with renal failure on a low phosphate diet, the nurse will inform the UAP to remove which food from the pts food tray? a. grape juice b. milk carton c. mixed green salad d. fried chicken breast

b. milk carton foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. green leafy veggies; high-fat foods; and fruits/juices are not high in phosphate and are not restricted.

which action can the RN who is caring for a critically ill patient with multiple IV lines delegate to an LPN/LVN? a. administer IV abx through the implantable port b. monitor the IV sites for redness, swelling, or tenderness c. remove the pts non tunneled subclavian central venous catheter d. adjust the flow rate of the 0.9% NS in the peripheral IV line

b. monitor the IV sites for redness, swelling, or tenderness an experienced LPN/LVN has the education, experience, and scope of practice to monitor IV sites for signs of infection. administration of meds, adjustment of infusion rates, and removal of central catheters in critically ill pts require RN level education and scope of practice.

a pt is admitted to the ED with severe fatigue and confusion. lab studies are done. which lab value will require the most immediate action by the nurse? a. arterial blood pH is 7.32 b. serum calcium is 18 mg/dL c. serum potassium is 5.1 mEq/L d. arterial oxygen saturation is 91%

b. serum calcium is 18 mg/dL the serum calcium is well above the normal level and puts the pt at risk for cardiac dysrhythmias. the nurse should initiate cardiac monitoring and notify the HCP. the potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the HCP about these values as well, but they are not immediately life threatening.

when assessing a pregnant pt with eclampsia who is receiving IV mag sulfate, which finding should the nurse report to the HCP immediately? a. the bibasilar breath sounds are decreased. b. the patellar and triceps reflexes are absent c. the pt has been sleeping most of the day d. the pt reports feeling sick to her stomach

b. the patellar and triceps reflexes are absent the loss of the DTR indicates that the pts mag level may be reaching toxic levels. nausea and lethargy also are side effects associated with mag elevation and should be reported, but they are not as significant as the loss of DTRs. the decreased breath sounds suggest that the pt needs to cough and deep breathe to prevent atelectasis.

the nurse is caring for a patient who has a central venous access device (CVAD). which action by the nurse is appropriate? a. avoid using friction when cleaning around the CVAD insertion site. b. use the push-pause method to flush the CVAD after giving meds c. obtain an order form the HCP to change CVAD dressing d. position the pts face toward the CVAD during injection cap changes.

b. use the push-pause method to flush the CVAD after giving meds the push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. to decrease infection risk, friction should be used when cleaning the CVAD insertion site. the dressing should be changed whenever it becomes damp, loose, or visibly soiled. the pt should turn away from the CVAD during cap changes

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a. "There is a decreased risk for infection when 25% dextrose is infused through a central line." b. "The prescribed infusion can be given much more rapidly when the patient has a central line." c. "The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line." d. "The required blood glucose monitoring is more accurate when samples are obtained from a central line."

c. "The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line." the 25% dextrose solution is hypertonic. shrinkage of RBCs can occur when solutions with dextrose concentrations greater than 10% are administered IV. blood glucose testing is not more accurate when samples are obtained from a central line. the infection risk is higher with a central catheter than with a peripheral IV. hypertonic or concentrated IV solutions are not given rapidly.

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided imagery.

c. Administer the prescribed normal saline bolus and insulin. the rapid, deep (kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. oxygen therapy is not indicated because there is no indication that the increased resp rate is related to hypoxemia. the resp pattern is compensatory, and the pt will not be able to slow the resp rate. lorazepam administration will slow the resp rate and increase the level of acidosis

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give the prescribed PRN morphine sulfate IV.

c. Auscultate the patient's breath sounds. the initial action should be to assess the pt further because the hx and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. the other actions may be appropriate, but further assessment of the pt is needed before notifying the HCP, offering reassurance, or administration of morphine.

An older pt receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which lab result should the nurse report to the healthcare provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca2+ 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO43- 4.8 mg/dL (1.55 mmol/L)

c. Na+ 154 mEq/L (154 mmol/L) the elevated serum sodium level is consistent with the pts neurologic symptoms and indicates a need for imeediate action to prevent further serious complications such as seizures. the potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. the phosphate level is normal.

the long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has low serum total protein level. which assessment finding indicates that the pts condition has improved? a. hematocrit 28% b. absence of skin tenting c. decreased peripheral edema d. blood pressure 110/72

c. decreased peripheral edema edema is caused by low oncotic pressure in individuals with low serum protein levels. the decrease in edema indicates an improvement in the pts protein status. Good skin turgor is an indicator of fluid balance, not protein status. a low hematocrit could be caused by poor protein intake. BP does not provide a useful clinical tool for monitoring protein status.

the nurse assesses a patient who has been hospitalized for 2 days. the pt has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. which assessment finding would be a priority for the nurse to report to the HCP? a. oral temp of 100.1 F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. gradually decreasing LOC d. weight gain of 2 pounds above the admission weight

c. gradually decreasing LOC the pts hx of change in LOC could be indicative of fluid and electrolyte disturbances: ECF excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. further diagnostic info is needed to determine the cause of the change in LOC and the appropriate interventions. the weight gain, elevated temp, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

a nurse is assessing a newly admitted pt with chronic heart failure who forgot to take prescribed meds and seems confused. the pt complains of just blowing up and has peripheral edema and SOB. which assessment should the nurse complete FIRST? a. skin turgor b. heart sounds c. mental status d. capillary refill

c. mental status increases in ECF can lead to swelling of cells in the CNS, initially causing confusion, which may progress to coma or seizures. although skin turgor, cap refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on pt outcomes as cerebral edema.

after receiving change-of-shift report, which pt should the nurse assess first? a. pt with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. pt with a serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. pt with a serum mag level of 1.1 mEq/L who has tremors and hyperactive DTRs d. pt with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

c. pt with a serum mag level of 1.1 mEq/L who has tremors and hyperactive DTRs the low mag level and neuromuscular irritability suggest that the pt may be at risk for seizures. the other pts have mild electrolyte disturbances and/or symptoms that require actions, but they are not at risk for life-threatening complications

a pt who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone. The nurse should notify the HCP about which assessment finding? a. reported weight gain b. serum hematocrit of 42% c. serum sodium level of 120 mg/dL d. total urinary output of 280 mL during past 8 hours

c. serum sodium level of 120 mg/dL hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. hyponatremia can cause confusion and other CNS effects. a critically low value likely needs to be treated. at least 30 mL/hr of urine output indicates adequate kidney function. the hematocrit level is normal weight gain is expected with SIADH because of water retention.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

d. Respiratory alkalosis This pH indicates that the pt has alkalosis and the low PaCOw indicates a resp cause. the other responses are incorrect based on the pH and normal HCO3

a pt who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. it is most appropriate for the nurse to take which action? a. assess for facial muscle spasms b. ask the pt about loose stools c. suggest that the pt avoid orange juice with meals d. ask the HCP to order a basic metabolic panel.

d. ask the HCP to order a basic metabolic panel. generalized weakness is a manifestation of hypokalemia. after the hCP orders the metabolic panel, the nurse should check the potassium level. facial muscle spasms might occur with hypocalcemia. OJ is high in potassium and would be advisable to drink if the pt was hypokalemic. loose stools are associated with hyperkalemia.

the nurse is caring for a patient who has a calcium level of 12.1 mg/dL. which nursing action should the nurse include on the care plan? a. maintain the pt on bed rest b. auscultate lung sounds every 4 hours c. monitor for trousseaus and chvostek's signs d. encourage fluid intake up to 4000 mL every day.

d. encourage fluid intake up to 4000 mL every day. to decrease the risk for renal calculi, the pt should have a fluid intake of 3000-4000 mL daily. ambulation helps decrease the loss of calcium from bone and is encouraged in pts with hypercalcemia. trousseaus and chvosteks signs are monitored when there is a possibility of hypocalcemia. there is no indication that the pt needs frequent assessment of lung sounds, although theses would be assessed every shift.

spironolactone (aldactone), an aldosterone antagonist, is prescribed for a pt. which statement by the pt indicates that the teaching about this medication has been effective? a. i will try to drink at least 8 glasses of water every day. b. i will use a salt substitute to decrease my sodium intake c. i will increase my intake of potassium-containing foods d. i will drink apple juice instead of orange juice for breakfast

d. i will drink apple juice instead of orange juice for breakfast because spironolactone is a potassium-sparing diuretic, pts should be taught to choose low-potassium foods (like apple juice) rather than foods that have higher levels of potassium (like citrus fruits) because the pt is using spironolactone as a diuretic, the nurse would not encourage the pt to increase fluid intake. teach pts to avoid salt substitutes, which are high in potassium

a pt is receiving a 3% saline continuous IV infusion for hyponatremia. which assessment data will require the most rapid response by the nurse? a. the pts radial pulse is 105 beats/min b. there is sediment and blood in the pts urine c. the BP increases from 120/80 to 142/92 d. there are crackles audible throughout both lung fields

d. there are crackles audible throughout both lung fields crackles throughout both lungs suggest that the pt may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. the increased pulse rate and BP and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.