Craven Ch 32: Fluid, Electrolytes, and Acid-Base

By which route do oxygen and carbon dioxide exchange in the lung? - osmosis - filtration - diffusion - active transport

- diffusion Explanation: Oxygen and carbon dioxide exchange in the lung's alveoli and capillaries by diffusion. Diffusion is the tendency of solutes to move freely throughout a solvent by moving from an area of higher concentration to an area of lower concentration.

A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant? - weight gain of 0.75 kg in a day - increased blood pressure - bounding pulse - slightly distended neck veins

- weight gain of 0.75 kg in a day Explanation: Although increased blood pressure, bounding pulse, and distended neck veins are signs of ECF volume excess, rapid weight gain (more than 0.5 kg per day) is the most significant symptom indicating ECF volume excess. A weight gain of 1 kg reflects retention of 1 L of ECF. Additionally, because the veins are very distensible, large volumes of fluid can be retained without any increase in blood pressure or changes in pulse or neck veins.

Which is not a primary intracellular electrolyte? - chloride - potassium - phosphate - sulfate

- chloride Explanation: Chloride, along with sodium and bicarbonate, are the primary ECF electrolytes.

A client is brought into the emergency department with a suspected opioid overdose. The nurse would anticipate that the client would most likely experience which acid-base imbalance? - Respiratory acidosis - Respiratory alkalosis - Metabolic acidosis - Metabolic alkalosis

- Respiratory acidosis Explanation: An overdose of an opioid would depress the client's neurologic function and subsequently his breathing ability. The client would most likely develop respiratory acidosis. Respiratory alkalosis is associated with hyperventilation. Metabolic acidosis can occur with loss of bicarbonate, as may happen with severe diarrhea, or with acid accumulation (e.g., ketoacids formed in uncontrolled diabetes mellitus or lactic acids produced by oxygen deprivation). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes of metabolic alkalosis.

Which is a common anion? - magnesium - potassium - chloride - calcium

- chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? - muscle twitching - distended neck veins - fingerprinting over sternum - nausea and vomiting

- distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? - "Fluid inside cells." - "Fluid outside cells." - "Fluid in the tissue space between and around cells." - "Watery plasma, or serum, portion of blood."

- "Fluid in the tissue space between and around cells." Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

A nurse is reviewing the arterial blood gas results of a client. Which pH value would the nurse document as indicating acidosis? - 7.30 - 7.37 - 7.41 - 7.47

- 7.30 Explanation: The normal pH ranges from 7.37 to 7.43. A pH of 7.30 indicates acidosis while a pH of 7.47 indicates alkalosis. A pH of 7.37 or 7.41 would be within normal limits.

A nurse is teaching a client about the newly prescribed furosemide and how it affects fluid and electrolyte balance. In addition to water, the nurse would explain that the drug also affects which electrolyte(s)? Select all that apply. - Sodium - Chloride - Potassium - Magnesium - Calcium - Phosphate

- Sodium - Chloride - Potassium - Magnesium Explanation: Diuretics are prescribed to increase the excretion of sodium, chloride, and water in clients with high blood pressure or with chronic heart, renal, or liver problems. At times, the medications may remove too much ECF from the body, resulting in a deficit. Diuretics, except for the potassium-sparing diuretics, also promote the excretion of potassium and magnesium from the body, increasing the risk of electrolyte deficits as well. Imbalances of calcium and phosphate are usually not associated with diuretic therapy.

A nurse suspects a client with electrolyte imbalances is experiencing hypomagnesemia. Which nursing assessment finding may indicate hypomagnesemia? - hyperactive deep tendon reflexes (DTRs) - hypoactive deep tendon reflexes (DTRs) - hyperthermia - hypothermia

- hyperactive deep tendon reflexes (DTRs) Explanation: Hypomagnesemia may lead to heart block, change in mental status, hyperactive deep tendon reflexes (DTRs), and respiratory paralysis.

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate? - "Granulocytes are a type of white blood cell that can help fight infection." - "Granulocytes replace clotting factors that are altered from infection." - "Granulocytes help third spacing of fluid that occurs with infection." - "Granulocytes help to control bleeding associated with infection."

- "Granulocytes are a type of white blood cell that can help fight infection." Explanation: Granulocytes are a type of white blood cell that are used to fight infection. All other options are incorrect statements related to granulocytes.

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? - 1+ - 2+ - 3+ - 4+

- 1+ Explanation: The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? - Slow the rate of IV fluids. - Remove the IV. - Apply a warm compress. - Elevate the arm.

- Remove the IV. Explanation: The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

A client has metabolic (nonrespiratory) acidosis. Which type of respirations would be assessed? - periods of apnea - decreased depth and rate - increased depth and rate - alternating fast and slow

- increased depth and rate Explanation: Metabolic (nonrespiratory) acidosis is a proportionate deficit of bicarbonate in the ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate. The lungs attempt to increase the excretion of carbon dioxide by increasing the rate and depth of respirations.

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? - maintenance of cell size - maintenance of blood volume - transportation of nutrients - removal of waste

- maintenance of cell size Explanation: The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? - excessive use of laxatives - diaphoresis - renal failure - increased cardiac output

- renal failure Explanation: Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

The health care provider is concerned that the client has hypokalemia. During the physical examination, which question should the nurse ask the client? - "Have you been experiencing chest pain?" - "Have you been experiencing muscle weakness or leg cramps?" - "Have you been having diarrhea?" - "Have you been experiencing difficulty breathing?"

- "Have you been experiencing muscle weakness or leg cramps?" Explanation: Hypokalemia is a potassium deficit. When the level of potassium decreases, potassium moves out of the cells, creating an intracellular potassium deficiency. Typical symptoms include muscle weakness and leg cramps. Hyperkalemia is likely to cause diarrhea. Hypokalemia is not known to cause chest pain or difficulty breathing, unless an arrhythmia occurs due to an imbalance in the potassium level.

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? - "I need to drink no more than 1,000 mL/day" - "I should drink 1,500 mL/day of fluid." - "I should drink 2,500 mL/day of fluid." - "I should drink more than 3,500 mL/day of fluid."

- "I should drink 2,500 mL/day of fluid." Explanation: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? - "I was breathing so fast because I was so anxious and in so much pain." - "I've been taking antacids almost every 2 hours over the past several days." - "I've had a fever for the past 3 days that just doesn't seem to go away." - "I've had a GI virus for the past 3 days with severe diarrhea."

- "I've been taking antacids almost every 2 hours over the past several days." Explanation: Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.

The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response? - "Fluid inside cells." - "Fluid outside cells." - "Fluid in the tissue space between and around cells." - "Watery plasma, or serum, portion of blood."

- "Watery plasma, or serum, portion of blood." Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? - 3,750 - 3,000 - 1,000 - 500

- 3,000 Explanation: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? - 3.5 cm H2O - 5 cm H2O - 9.5 cm H2O - 12 cm H2O

- 3.5 cm H2O Explanation: The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.

A client's intake and output is being measured and recorded each shift. The client has had the following intake:3 oz apple juice4 oz tea5 oz pureed chicken2 oz mashed potatoes4 oz orange gelatin2 oz vanilla ice cream

- 390 Explanation: Intake measurements include all oral and parenteral fluids. Oral fluids include any liquids ingested or any foods that become liquid at room temperature. Gelatin and ice cream are examples of solid foods to include. Pureed foods is not considered fluid intake nor is mashed potatoes. Based on the measurements, the client consumed 13 oz of fluid. One ounce is equal to 30 ml, so 13 oz of fluid is equal to 390 mL.

The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate? - 42 gtt/min - 25 gtt/min - 125 gtt/min - 20 gtt/min

- 42 gtt/min Explanation: When infusing by gravity, divide the total volume in mL (1,000 mL) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtt/mL. The correct answer is 42 gtt/min.

A nurse is preparing to measure jugular venous distention in a client. To ensure accuracy, the nurse would elevate the head of the client's bed to: - 30 degrees - 45 degrees - 60 degrees - 90 degrees

- 45 degrees Explanation: When measuring jugular venous distention, the nurse would elevate the head of the client's bed to 45 degrees so that the sternal angle is 5 cm above the right atrium. Any other elevation would lead to inaccurate results.

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O? - 23-year-old with ulnar and radial fracture - 34-year-old whose urinary catheter was discontinued yesterday - 48-year-old who has had a bowel movement after surgery - 55-year-old with congestive heart failure on furosemide

- 55-year-old with congestive heart failure on furosemide Explanation: Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O.

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? - 83 mL/hr - 103 gtts/hr - 100 mL/hr - 13 mL/hr

- 83 mL/hr Explanation: When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (12). This is 83 mL/hr. Other options are incorrect.

What is the lab test commonly used in the assessment and treatment of acid-base balance? - Complete blood count - Basic metabolic panel - Arterial blood gas - Urinalysis

- Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level.

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply. - Increase oral intake to flush excess fluids. - Ask provider to order a low-salt diet. - Administer furosemide as ordered. - Reduce infusing fluid volume as ordered. - Treat the underlying condition that contributes to increased fluid volume.

- Ask provider to order a low-salt diet. - Administer furosemide as ordered. - Reduce infusing fluid volume as ordered. - Treat the underlying condition that contributes to increased fluid volume. Explanation: Control of edema, and thus restoration of fluid balance, can be accomplished by treating the disorder contributing to the increased fluid volume, restricting or limiting oral fluids, reducing salt consumption, discontinuing IV fluid infusions or reducing the infusing volume, and/or administering drugs that promote urine elimination. Increasing oral intake to flush excess fluids is not an appropriate intervention.

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? - Avoid salty or excessively sweet fluids. - Use regular gum and hard candy. - Eat crackers and bread. - Use an alcohol-based mouthwash to moisten your mouth.

- Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.

A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate? - Avoid use of a tourniquet. - Select a large-gauge needle. - Consider venipuncture in the foot where veins are less visible. - Use the client's nondominant hand to hold the vein in place.

- Avoid use of a tourniquet. Explanation: It may be possible and advantageous to avoid using a tourniquet when accessing a vein that is visually prominent on an older adult. Use of a tourniquet may result in bursting the vein, sometimes referred to as "blowing the vein," when it is punctured with a needle. Using a large-gauge needle may also "blow" the vein. A small gauge or butterfly should be used. Using veins in the foot is not appropriate nor is attempting to hold the vein in place.

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? - Compare the client's intake with the normal range of adult fluid intake. - Report the exact milliliter of intake to the health care provider's office nurse. - Compare the total intake and output of fluids for the 24 hours. - Ensure that the information is included in the verbal end-of-shift report.

- Compare the total intake and output of fluids for the 24 hours. Explanation: The nurse must pay attention to certain parameters when assessing a client's fluid status. This means comparing the total intake and output of fluids for a given period of time. It is more accurate to compare the client's fluid intake with the previous time period than another client. The nurse does not need to report that fluid to the health care provider's nurse but rather document the information in the client's health record and if there are differences then that information should be reported to the health care provider and the end-of-shift report.

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system? - Abdominal distention - Vomiting - Paralytic ileus - Diarrhea

- Diarrhea Explanation: The client with hyperkalemia would experience diarrhea. Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia.

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? - Bowel motility will be restored within 24 hours after beginning supplemental K+. - ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. - ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. - Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.

- ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Explanation: If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.

A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed? - Isotonic - Hypertonic - Hypotonic - Osmolar

- Hypertonic Explanation: A hypertonic solution has a greater osmolarity than plasma, which causes water to move out of the cells and be drawn into the intravascular compartment. A hypotonic solution has a lower osmolarity than plasma; therefore, fluid would move out of the intravascular space rather than pulling fluids from the tissues into the vascular space. An isotonic fluid remains in the intravascular compartment without any net flow across the semipermeable membrane. The concentration of particles in a solution is referred to as the osmolarity of a solution.

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances? - Infants - Toddlers - Adolescents - School-age children

- Infants Explanation: Infants have a far greater volume of total fluid as a percentage of body weight than other children . However, this high percentage of fluid does not give infants a greater reserve against fluid deficit. Instead, it creates a vulnerability to fluid deficit due to the high percentage of fluid required for homeostasis. In addition, kidney immaturity and increased body surface area in relation to body size place infants at greater risk than older children or adults for fluid and electrolyte imbalances.

Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this? - Infants have less total body fluid and ECF than adults. - Infants have more total body fluid and ECF than adults. - Infants drink less fluid than adults. - Infants lose more fluids through output than adults.

- Infants have more total body fluid and ECF than adults. Explanation: An infant has considerably more total body fluid and ECF than an adult does. Because ECF is more easily lost from the body than ICF, infants are more prone to fluid volume deficits. Because infants' main food is from breast milk or formula, typically infants drink more than adults.

A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply. - Metabolic alkalosis - Hypokalemia - Respiratory acidosis - Hypernatremia - Hypercalcemia

- Metabolic alkalosis - Hypokalemia Explanation: If sufficient gastric juice (ECF with additional acid) is lost from the stomach, then consequently hydrogen, sodium, and chloride ions are depleted, increasing the risk of ECF volume deficit and/or metabolic alkalosis. Gastric fluid also is high in potassium, and excessive losses may contribute to hypokalemia. Respiratory acidosis would be more likely to occur with an underlying lung disorder, such as asthma or emphysema. Vomiting leads to a loss of sodium, so elevated sodium levels would be unlikely. Imbalances of calcium are not typically associated with imbalances associated with vomiting.

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium? - Insulin promotes the transfer of potassium from the extracellular fluid into skeletal muscle and liver cells. - Aldosterone enhances renal excretion of potassium. - A person loses approximately 30 mEq (30 mmol) of potassium. - Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L).

- Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L). Explanation: Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? - Ask the client every hour to drink more fluid. - Offer small amounts of preferred beverage frequently. - Have a loved one tell the client to drink more. - Leave water on the bedside table.

- Offer small amounts of preferred beverage frequently. Explanation: Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

A group of nursing students is reviewing information about the body's electrolytes. The students demonstrate understanding of the material when they identify which electrolyte as having a reciprocal relationship with calcium? - Sodium - Potassium - Phosphorus - Magnesium

- Phosphorus Explanation: Calcium and phosphorus typically show a reciprocal relationship such that an increase in one leads to a decrease in the other. Sodium is the major cation in the extracellular fluid. Sodium, potassium, and magnesium do not share a relationship with calcium.

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? - Sacral area - Face - Hands - Abdomen

- Sacral area Explanation: The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. The edema cannot be assessed in the face, hands and abdomen, as these are not dependent areas.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? - Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). - Sodium is regulated by the renin-angiotensin-aldosterone system. - If sodium is low, it means that there is not enough water. - Sodium is not regulated by natriuretic peptides.

- Sodium is regulated by the renin-angiotensin-aldosterone system. Explanation: Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.

The nurse is educating a client about the function of sodium in the body. What education points would the nurse make? Select all that apply. - Sodium does not influence ICF volume. - Sodium is the primary regulator of ECF volume - The daily value of sodium cited on nutrition facts labels is 1,200 mg. - Sodium is normally maintained in the body within a relatively narrow range, and deviations quickly result in serious health problems. - The normal extracellular concentration of sodium is 85 to 95 mEq/L (85 to 95 mmol/L). - Sodium participates in the generation and transmission of nerve impulses.

- Sodium is the primary regulator of ECF volume - Sodium is normally maintained in the body within a relatively narrow range, and deviations quickly result in serious health problems. - Sodium participates in the generation and transmission of nerve impulses. Explanation: Sodium primarily regulates extracellular fluid volume and plays a role in muscle contraction and transmission of nerve impulses. The range of serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L). Sodium does influence ICF volume. The daily suggested intake of sodium is not more than 2,300 mg/day or no more than 1,500 mg/day for persons 51 years of age and older.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? - Allow nothing by mouth. - Give the client a glass of orange juice with added sugar. - Encourage fluid intake. - Start an IV of normal saline as prescribed.

- Start an IV of normal saline as prescribed. Explanation: To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.

The nurse is assessing an adult client who has presented to the emergency department with general weakness. The nurse reviews the client's health record to find there is no history of underlying health conditions. The nurse will begin preparing for the insertion of a peripheral intravenous line if which assessment finding(s) are present? Select all that apply. - The client has experienced 24 hours of diarrhea. - The client reports using laxative substances daily. - The client has been vomiting for several days. - The client is only willing to drink juices. - The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). - The client has severe iron-deficiency anemia.

- The client reports using laxative substances daily. - The client has been vomiting for several days. - The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). - The client has severe iron-deficiency anemia. Explanation: Intravenous fluids or other fluids that are administered intravenously are given for various reasons related to the client's fluid and electrolyte status. A client who is severely dehydrated may have difficulty replenishing the fluid loss on one's own by oral intake alone. In addition, severe dehydration leads to significant electrolyte imbalance. Overuse of laxatives and enemas can cause fluid and electrolyte depletion. A client who has been vomiting for several days will not be able to tolerate oral intake of fluids. A serum potassium level of 2.0 mEq/l (2.0 mmol/l) indicates hypokalemia, because the normal range is 3.6 to 5.2 mEq/l (3.6 to 5.2 mmol/l). Hypokalemia can have harmful cardiac and neurological effects and must be treated immediately, while some clients with hypokalemia will be treated with an oral supplement. For a serum level so low, the best option is intravenous administration of fluid with potassium. A client with severe iron-deficiency anemia will require transfusion of blood products. An intravenous line will be required for this intervention. Experiencing diarrhea for 24 hours does not put the client at risk for dehydration. Diarrhea does not limit the client's ability to take fluids orally. The client who is able to tolerate drinking juice will not need an intravenous line. Various types of fluids can be effective in rehydration.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? - To assure the IV solution is appropriate for this administration - To assure effective administration of the prescribed IV solution - To provide for effective time management in the administration of the prescribed IV solution - To demonstrate effective nursing care in the administration of the prescribed IV solution

- To assure the IV solution is appropriate for this administration Explanation: The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is appropriate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.

A nursing instructor is preparing a class presentation for a group of nursing students on fluid balance and developmental considerations. What would the instructor likely include when describing newborns and infants? Select all that apply. - Water makes up a larger percentage of their body weight. - This age group loses water less readily . - Greater amounts of water are found in the extracellular fluid compartment. - The infant's kidneys are readily able to concentrate urine. - Insensible fluid losses are greater in this age group.

- Water makes up a larger percentage of their body weight. - Greater amounts of water are found in the extracellular fluid compartment. - Insensible fluid losses are greater in this age group. Explanation: Infants have a proportionately larger percentage of total body weight as water (70% to 80%) than do adults (60%). A greater amount of the fluid is contained within the ECF compartment in infants than within that of adults. Because infants also have a greater surface area in relation to weight, they can lose a proportionately larger volume of fluid through the skin. Fluid requirements vary according to age, as do normal urine outputs. The infant's kidneys are immature and lack the ability to concentrate urine fully. Metabolic and respiratory rates are high in infants, contributing to increased insensible fluid loss. Fluid loss can occur very rapidly in this age group.

Which statement most accurately describes the process of osmosis? - Water moves from an area of lower solute concentration to an area of higher solute concentration. - Solutes pass through semipermeable membranes to areas of lower concentration. - Water shifts from high-solute areas to areas of lower solute concentration. - Plasma proteins facilitate the reabsorption of fluids into the capillaries.

- Water moves from an area of lower solute concentration to an area of higher solute concentration. Explanation: Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the reabsorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? - calcium and phosphorus - potassium and sodium - chloride and magnesium - potassium and chloride

- calcium and phosphorus Explanation: The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? - cardiac irregularities - muscle weakness - increased intracranial pressure (ICP) - metabolic acidosis

- cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which will the nurse document on the I&O record? Select all that apply. - client drinking milk - client's urination - client eating a sandwich - vomiting - infusion of intravenous solution

- client drinking milk - client's urination - vomiting - infusion of intravenous solution Explanation: The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output.

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? - daily weights - daily BUN and serum creatinine monitoring - output measurements - daily electrolyte monitoring

- daily weights Explanation: Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client's daily weight may be the more accurate measurement of a client's fluid status. Laboratory tests are helpful in assessing kidney function and electrolyte values, but do not provide the precise information on fluid losses or gains as is provided by a daily weight (at the same time, using the same scale). Output measurements are not meaningful without intake measurements.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? - decreased blood volume and intracellular dehydration - increased blood volume and intracellular dehydration - increased blood volume and extracellular overhydration - decreased blood volume and extracellular overhydration

- decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.

A client is taking a diuretic that increases urinary output. What nursing concern is appropriate to base an educational plan? - altered skin integrity - decreased fluid volume risk - altered urinary elimination - urinary retention

- decreased fluid volume risk Explanation: An appropriate nursing concern for a client taking a diuretic that increases urinary output would be decreased fluid volume risk. The nurse will educate the client on the symptoms of dehydration, how to increase fluid intake, and the need to maintain a record of daily weights. Diuretics do not affect elimination or cause urinary retention. In addition, diuretics do not affect the skin.

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is: - fluid volume deficit. - myocardial infarction. - fluid volume excess. - atelectasis.

- fluid volume excess. Explanation: A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess.

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? - isotonic - hypotonic - hypertonic - hypotonic, followed by isotonic

- hypertonic Explanation: A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance? - hyponatremia - hypokalemia - hypercalcemia - hypermagnesemia

- hypokalemia Explanation: All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia.

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find? - hyperphosphatemia - hyperchloremia - hypokalemia - hypomagnesemia

- hypokalemia Explanation: Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.

The nurse is caring for a client who has had severe diarrhea for 24 hours. Which fluid does the nurse anticipate infusing? - isotonic - hypotonic - hypertonic - hypertonic, followed by isotonic

- hypotonic Explanation: A hypotonic solution contains fewer dissolved substances than normally found in plasma. It is administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. The water also passes through capillary walls and becomes distributed within other body cells and the interstitial spaces. Hypotonic solutions, therefore, are an effective way to rehydrate clients experiencing fluid deficits.

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? - hypervolemia - hypovolemia - edema - circulatory overload

- hypovolemia Explanation: The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.

The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to: - increase in muscle mass. - smaller stomach capacity. - decreased skin area. - increase in fat cells.

- increase in fat cells. Explanation: The decreasing percentage of body fluid in older adults is related to an increase in fat cells. In addition, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults. Older adults do not have an increase muscle mass, smaller stomach capacity, or decrease skin area.

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? - increased hydrostatic pressure - decreased colloid oncotic pressure - blockage of the lymph nodes - increased capillary permeability

- increased hydrostatic pressure Explanation: The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by: - increasing ventilation through the lungs. - increasing the excretion of HCO3− into the urine. - decreasing the excretion of H+ ion into the urine. - preventing excretion of acids into the urine.

- increasing ventilation through the lungs. Explanation: The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. To compensate for respiratory alkalosis, the kidneys increase the excretion of HCO3− to the urine. Kidneys compensate for respiratory acidosis by increasing the excretion of H+ ion into the urine. The kidneys respond to metabolic alkalosis by retaining acid and excreting HCO3−.

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? - interstitial - extracellular - intracellular - intravascular

- intracellular Explanation: Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment.

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? - muscle cramping and tetany - nausea, vomiting, and constipation - diminished cognitive ability and hypertension - muscle weakness, fatigue, and constipation

- muscle cramping and tetany Explanation: Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells? - albumin - plasma - granulocytes - normal saline solution

- plasma Explanation: The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells. Albumin pulls third-spaced fluid by increasing colloidal osmotic pressure but does not restore clotting factors. The infusion of granulocytes improves the ability of the body to overcome infection. Normal saline is an isotonic solution that replaces fluid loss but does not replace clotting factors.

A client has been admitted to the hospital with a diagnosis of acute renal failure, a health problem that necessitates vigilant monitoring of the client's fluid balance. What is the most accurate way that the care team can achieve this assessment goal? - weighing the client once per day - daily assessment of the client's skin turgor - daily laboratory studies - measurement of urine concentration

- weighing the client once per day Explanation: Because of variations and potential oversights in the monitoring of clients' intake and output, daily weights are considered one of the more accurate measures of fluid balance. Skin turgor is not a reliable assessment in isolation. Daily laboratory studies may reveal the physiologic causes and consequences of fluid imbalance, but they do not gauge the problem itself. Similarly, the measurement of urine volume and concentration will likely be confounded by the client's diagnosis of renal failure, though each would certainly be monitored. Output is not meaningful data without considering fluid intake.

A client is preparing for discharge to home following a diagnosis of hypoparathyroidism with associated low parathyroid hormone. Which food(s) will the nurse include when creating a diet-based teaching plan for the client? Select all that apply. - peanuts - yogurt - broccoli - tofu - peaches - bananas

- yogurt - broccoli - tofu Explanation: The parathyroid produces the hormone parathormone (PTH), which regulates serum calcium levels. A low level of PTH results in hypocalcemia. The nurse's diet-based teaching plan should include foods that include high levels of calcium, such as dairy products like yogurt and cheese. Dark green vegetables like broccoli, spinach, or greens are important sources of calcium. Oysters, salmon, and sardines are also great sources of calcium. Peanuts will help raise the levels of sodium, but not calcium. Other sources of sodium are bouillon, canned soups, and snack foods. A client can increase their levels of potassium by eating fruits such as peaches and other fruits, vegetables, or juices like orange and tomato juices. Bananas are excellent sources of magnesium, as well as potassium. Other sources of magnesium include eggs, milk, and whole grains.