ch. 13: fluid and electrolytes
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Crackles in the lung fields Distended neck veins Decreased blood pressure Shortness of breath Bradycardia
Distended neck veins Crackles in the lung fields Shortness of breath Explanation: Clinical manifestations of FVE (hypervolemia) include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.
Question 5 of 5 Hypokalemia can cause which symptom to occur? Decreased sensitivity to digitalis Production of concentrated urine Increased release of insulin Excessive thirst
Excessive thirst Explanation: If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine and excessive thirst. Potassium depletion depresses the release of insulin and results in glucose intolerance. Decreased sensitivity to digitalis does not occur with hypokalemia.
You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema? Generalized Dependent Brassy Pitting
Generalized Explanation: There may be generalized edema in all the interstitial spaces, which sometimes is called brawny edema or anasarca. Options B and D are not part of the process of third-spacing fluid. Option C is a distractor for this question. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018.
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? Hypovolemia contains only low blood volume. Similar causes are present in both conditions. In dehydration, only extracellular is depleted. Both conditions result in abnormal laboratory studies.
In dehydration, only extracellular is depleted. Explanation: 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.
Which condition might occur with respiratory acidosis? Increased intracranial pressure Decreased pulse Mental alertness Decreased blood pressure
Increased intracranial pressure Explanation: If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.
A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia? hypomagnesemia hypercalcemia hypervolemia hypermagnesemia
hypomagnesemia Explanation: 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 additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.
A client with respiratory acidosis is admitted to the intensive care unit for close observation. What client complication associated with respiratory acidosis would the nurse observe? stroke papilledema hyperglycemia seizures
papilledema. If respiratory acidosis is severe, intracranial pressure may rise, causing papilledema.
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? Interstitial fluid Intracellular fluid Extracellular fluid Intravascular fluid
Intracellular fluid Explanation: 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.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? Pulse Blood pressure Respirations Temperature
Pulse Explanation: An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client's pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing respirations and temperature because these aren't affected by the serum potassium level.
The nurse knows which is the normal serum value for potassium? 96-106 mEq/L (96-106 mmol/L). 8.5-10.5 mg/dL (2.13-2.63 mmol/L). 3.5-5.0 mEq/L (3.5-5.0 mmol/L). 135-145 mEq/L (135-145 mmol/L).
3.5-5.0 mEq/L (3.5-5.0 mmol/L). Explanation: Serum potassium must be within normal limits to prevent cardiac dysrhythmia. Normal serum sodium is 135-145 mEq/L (3.5-5.0 mmol/L). Normal serum chloride is 96-106 mEq/L (96-106 mmol/L). Normal total serum calcium is 8.5-10.5 mg/dL (2.13-2.63 mmol/L).
A patient is admitted with a diagnosis of renal failure. The patient complains of "stomach distress" and describes ingesting several antacid tablets over the past 2 days. Blood pressure is 110/70 mm Hg, face is flushed, and the patient is experiencing generalized weakness. Which is the most likely magnesium level associated with the symptoms the patient is having? 1 mEq/L 2 mEq/L 11 mEq/L 5 mEq/L
5 mEq/L Explanation: Magnesium excess (>2.7 mEq/L) is associated with the following symptoms: flushing, hypotension, muscle weakness, drowsiness, hypoactive reflexes, depressed respirations, and cardiac arrest. The respiratory center is depressed when serum magnesium levels exceed 10 mEq/L (5 mmol/L). This is not present in this patient, so the magnesium level is unlikely to be 11 mEq/L. Coma, atrioventricular heart block, and cardiac arrest can occur when the serum magnesium level is greatly elevated and not treated.
What percentage of potassium excreted daily leaves the body by way of the kidneys? 40 60 80 20
80 Explanation: To maintain the potassium balance, the renal system must function, because 80% of the potassium excreted daily leaves the body by way of the kidneys. The other numerical values are incorrect.
A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply. Blood urea nitrogen (BUN) of 23 mg/dL Serum sodium of 148 mEq/L Serum glucose of 90 mg/dL Hematocrit level of 48% Urine specific gravity of 1.03 Serum osmolality of 310 mOsm/kg
Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Urine specific gravity of 1.03 Explanation: Severe dehydration is associated with an increased BUN (N = 10 to 20 mg/dL), serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L) and urine specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would also be elevated but are within normal range for this question. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Laboratory Tests for Evaluating Fluid Status, pp. 255-256.
A fluid volume deficit can be caused by either dehydration or hypovolemia. What is the distinction between the two? In hypovolemia all fluid compartments have decreased volumes. In dehydration intracellular fluid volume is depleted. In hypovolemia only blood volume is low. In dehydration only blood volume is low.
In hypovolemia only blood volume is low.
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? Tetanic contractions Polyuria Jugular vein distention Weight loss
Jugular vein distention Explanation: Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.
The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a client experiencing hypercalcemia. Which ECG change is typically associated with this electrolyte imbalance? Prolonged QT intervals Prolonged PR intervals Peaked T waves Elevated ST segments
Prolonged PR intervals Explanation: Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium concentration. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 276. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 276
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? Restricting sodium intake to 1 gm/day Administering vasopressin as ordered Restricting fluids to 800 ml/day Elevating the head of the client's bed to 90 degrees
Restricting fluids to 800 ml/day Explanation: Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant? Urine specific gravity of 1.025 Serum sodium level of 132 mEq/L Blood urea nitrogen (BUN) level of 29 mg/dl Serum potassium level of 3 mEq/L
Serum potassium level of 3 mEq/L Explanation: A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding. In a client with a potential fluid volume imbalance, such as from vomiting, the other options are expected but none are as life-threatening as hypokalemia. A BUN level of 29 mg/dl indicates slight dehydration. A serum sodium level of 132 mEq/L is slightly below normal but not life-threatening. A urine specific gravity of 1.025 is normal.
The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia? Select all that apply. Lethargy Dehydration Tachypnea Hypotension Weakness
Tachypnea Weakness Lethargy Explanation: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride concentration is accompanied by a high sodium concentration and fluid retention.
Which of the following may be the first sign of respiratory acidosis in anesthetized patients? Ventricular fibrillation Mental cloudiness Increased pulse Dull headache
Ventricular fibrillation Explanation: Ventricular fibrillation may be the first sign of respiratory acidosis in anesthetized patients. Clinical signs in acute and chronic respiratory acidosis include sudden hypercapnia that can cause increased pulse and respiratory rate, mental cloudiness, dull headache or weakness. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 270. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 270
A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of: a. Increased serum HCO3. d. Decreased PaCO2. b. Increased PaCO2. c. Decreased serum HCO3.
b. Increased PaCO2. Explanation: The respiratory system compensates by decreasing ventilation to conserve CO2 and increase the PaCO2.
A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment? bowel sounds electrocardiogram (ECG) results respiratory rate neuromuscular function
electrocardiogram (ECG) results Explanation: Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
A nurse evaluates a client's laboratory results. What is a factor that may be affecting an increase in serum osmolality? hyponatremia free water loss diuretic use overhydration
free water loss Explanation: Osmolality measures the solute concentration per kilogram in blood and urine. Water loss in the serum would increase the solute concentration. Free water loss is a factor increasing serum osmolality. Diuretic use, overhydration, and hyponatremia are factors decreasing serum osmolality. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Table 13-3 Factors Affecting Serum and Urine Osmolality, p. 255.
A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypertension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? hypercalcemia hypocalcemia hyperkalemia hypokalemia
hypokalemia Explanation: Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.
Oncotic pressure refers to the excretion of substances such as glucose through increased urine output. amount of pressure needed to stop the flow of water by osmosis. number of dissolved particles contained in a unit of fluid. osmotic pressure exerted by proteins.
osmotic pressure exerted by proteins. Explanation: Oncotic pressure is a pulling pressure exerted by proteins such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when urine output increases as a result of excretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? pH, 7.25; PaCO2 50 mm Hg pH, 7.40; PaCO2 35 mm Hg pH, 7.35; PaCO2 40 mm Hg pH, 7.5; PaCO2 30 mm Hg
pH, 7.25; PaCO2 50 mm Hg Explanation: In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.
Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28
pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis, where only gastric fluid is lost. The other results do not represent metabolic alkalosis.
A client diagnosed with hypernatremia needs fluid volume replacement. What intravenous solution would be the safest for the nurse to administer? 5% dextrose in normal saline solution 0.45% sodium chloride 5% dextrose in water 0.9% sodium chloride
0.45% sodium chloride Explanation: A hypotonic solution (half-strength saline) is the solution of choice and considered safer than 5% dextrose in water because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. An isotonic solution (0.9%) is not desirable as a supplement because it provides Na and CL.
The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? 130 mEq/L 115 mEq/L 145 mEq/L 160 mEq/L
115 mEq/L Explanation: Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. The severity of symptoms increases with the degree of hyponatremia and the speed with which it develops. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, Sodium Deficit (Hyponatremia), p. 265.
It is important for a nurse to know how to calculate the corrected serum calcium level for a patient when hypocalcemia is seen along with low serum albumin levels. Calculate the corrected serum calcium when the serum calcium is 9 mg/dL and the serum albumin is 3 g/dL. 12 mg/dL 10.3 mg/dL 9.8 mg/dL 11 mg/dL
9.8 mg/dL Explanation: To calculate corrected serum calcium, subtract the normal serum albumin level of 4 g/dL from the reported albumin level of 3 g/dL, multiply that value (1) by 0.8 (constant factor) and then add that result (0.8 mg) to the reported serum level of 9 mg/dL. Therefore, 9 + 0.8 = 9.8 mg/dL (corrected value). Note: a constant factor of 0.8 is used because, for every decrease in serum albumin of 1 g/dL below 4 g/dL, the total serum calcium level is underestimated by 0.8 mg/dL. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, Chart 13-2: Calculating Corrected Serum Calcium Level, p. 274.
The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition? Dehydration Hypomagnesemia Hypokalemia Hypocalcemia
Hypocalcemia Explanation: 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. There is no such risk in dehydration, hypokalemia, or hypomagnesemia.
A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.) Tachycardia Oliguria Tachypnea Hypertension Bradycardia
Oliguria Tachycardia Tachypnea Explanation: Hypovolemia, or fluid volume deficit, is indicated by decreased, not increased, blood pressure (hypotension), oliguria, tachycardia (not bradycardia), and tachypnea. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Table 13-4 Fluid Volume Disturbances, p. 259. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259
Which condition leads to chronic respiratory acidosis in older adults? Thoracic skeletal change Overuse of sodium bicarbonate Erratic meal patterns Decreased renal function
Thoracic skeletal change Explanation: Poor respiratory exchange as the result of chronic lung disease, inactivity, or thoracic skeletal changes may lead to chronic respiratory acidosis. Decreased renal function in older adults can cause an inability to concentrate urine and is usually associated with fluid and electrolyte imbalance. A poor appetite, erratic meal patterns, inability to prepare nutritious meals, or financial circumstances may influence nutritional status, resulting in imbalances of electrolytes. Overuse of sodium bicarbonate may lead to metabolic alkalosis.
A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? furosemide hydrochlorothiazide metolazone spironolactone
furosemide Explanation: Furosemide is the only loop diuretic choice. Hydrochlorothiazide and metolazone are thiazide diuretics that block sodium reabsorption. Spironolactone is a potassium-sparing diuretic that prevents sodium absorption. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 263. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 263
You are making rounds on your clients. You find one of your clients struggling to breathe, appears confused, has tachycardia, and the skin appears dusky. What should you do to restore normal pH if ventilation efforts are not very successful? Give bronchodilators. Infuse magnesium sulfate. Start potassium IV. Administer sodium bicarbonate IV.
Administer sodium bicarbonate IV. Explanation: When the client makes frantic efforts to breathe, breathes slowly, or stops breathing, and has tachycardia, and the skin appears dusky (cyanosis), the condition is likely to be acute respiratory acidosis. The accumulation of CO2 leads to behavioral changes, including confusion. Excess carbonic acid pulls pH below 7.35. The nurse should administer sodium bicarbonate IV to balance the acid and bring the pH to a normal level. Bronchodilators may be useful in chronic respiratory acidosis but not in the acute version. Potassium (needed in hypokalemia) and magnesium sulfate (needed in hypomagnesemia) have no role in acute respiratory acidosis.
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. Absence of ketones in urine Electrolyte imbalance A low urine specific gravity An elevated hematocrit level Low protein level in the urine
An elevated hematocrit level Electrolyte imbalance Explanation: Dehydration is a common primary or secondary diagnosis in health care. 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Laboratory Tests for Evaluating Fluid Status, p. 255. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 255
The nurse is caring for a patient with a diagnosis of hyponatremia. Which nursing intervention is appropriate to include in the plan of care for this patient? Select all that apply. Encouraging the use of salt substitute instead of salt Monitoring neurologic status Restricting tap water intake Encouraging the intake of low-sodium liquids Assessing for symptoms of nausea and malaise
Assessing for symptoms of nausea and malaise Monitoring neurologic status Restricting tap water intake Explanation: For patients at risk of hyponatremia, the nurse closely monitors laboratory values (i.e., sodium) and stays alert for GI manifestations such as anorexia, nausea, vomiting, and abdominal cramping. The nurse must be alert for central nervous system changes, such as lethargy, confusion, muscle twitching, and seizures. Neurologic signs are associated with very low sodium levels that have fallen rapidly because of fluid overloading. For a patient with abnormal loss of sodium who can consume a general diet, the nurse encourages intake of foods and fluids with high sodium content. For example, broth made with one beef cube contains approximately 900 mg of sodium; 8 oz of tomato juice contains approximately 700 mg of sodium. If the primary problem is water retention, it is safer to restrict fluid intake than to administer sodium.
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? Hypertension Jaundice Chest pain Slow pulse
Chest pain Explanation: Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.
A client presents with severe diarrhea and a history of chronic renal failure to the emergency department. Arterial blood gas results are as follows: pH 7.30 PaO2 97 PaCO2 37 HCO3 18 The nurse would expect which of the following sets of assessment findings? Confusion, respiratory rate 8 breaths/min, dry skin Clammy skin, blood pressure 86/46, headache Blood pressure 188/120, nausea, vomiting Headache, blood pressure 90/54, dry skin
Clammy skin, blood pressure 86/46, headache Explanation: Metabolic acidosis, a common clinical disturbance, is characterized by decreased pH and plasma bicarbonate concentration. Common causes of metabolic acidosis include diarrhea, chronic renal failure, use of diuretics, intestinal fistulas, and ureterostomies. The client will experience the following signs and symptoms: headache, confusion, increased respiratory rate, nausea, vomiting, cold and clammy skin, and decreased blood pressure.
Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30mmHg; 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? Compensated respiratory alkalosis Uncompensated respiratory alkalosis Compensated metabolic acidosis Compensated metabolic alkalosis
Compensated respiratory alkalosis Explanation: 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 27mEq/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).
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Flaccidity and thirst Sunken eyeballs and spasticity Tetany and increased blood urea nitrogen (BUN) levels
Confusion and seizures Explanation: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 261.
A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. Shoulder pain Dyspnea Cyanosis Crackles on auscultation Tachycardia Hypertension
Cyanosis Shoulder pain Dyspnea Tachycardia Explanation: Hypotension, along with the other correct choices, is a manifestation of an air embolism. Crackles on auscultation is a major indicator of circulatory system overload. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, Air Embolism, p. 291.
A client was admitted to the 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 family? Select all that apply. Drink caffeinated beverages to retain fluid. Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst Drink carbonated beverages to help balance fluid volume.
Drink at least eight glasses of fluid each day.Drink water as an inexpensive way to meet fluid needs.Respond to thirst
The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte imbalance? Hypermagnesemia Hypocalcemia Hyperchloremia Hyponatremia
Hypocalcemia Explanation: The client is experiencing an elevated serum phosphorus concentration. Hyperphosphatemia is defined as a serum phosphorus that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus concentration tends to cause a low serum calcium concentration.
An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? Hypernatremia Hypophosphatemia Hypokalemia Hyperkalemia
Hypokalemia Explanation: Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium-losing diuretics, such as furosemide, can induce hypokalemia. Hyperkalemia refers to increased potassium levels. Loop diuretics can bring about lower sodium levels, not hypernatremia. Furosemide does not affect phosphorus levels.
A patient has a serum osmolality of 250 mOsm/kg. The nurse knows to assess further for: Hyponatremia. Dehydration. Acidosis. Hyperglycemia.
Hyponatremia. Explanation: Decreased serum sodium is a factor associated with decreased serum osmolality. Dehydration and hyperglycemia are associated with increased serum osmolality; acidosis is associated with increased urine osmolality.
A client with a magnesium concentration of 2.6 mEq/L (1.3 mmol/L) is being treated on a medical-surgical unit. Which treatment should the nurse anticipate will be used? Dialysis Oral magnesium oxide Fluid restriction Intravenous furosemide
Intravenous furosemide Explanation: The nurse should anticipate the administration of furosemide for the treatment of hypermagnesemia. Administration of loop diuretics (e.g., furosemide) and sodium chloride or lactated Ringer intravenous solution enhances magnesium excretion in clients with adequate renal function. Fluid restriction is contraindicated. The client should be encouraged to increase fluids to promote the excretion magnesium through the urine. Magnesium oxide is contraindicated because it would further elevate the client's serum magnesium concentration. In acute emergencies, when the magnesium concentration is severely elevated, hemodialysis with a magnesium-free dialysate can reduce the serum magnesium to a safe concentration within hours.
Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? Weight loss Jugular vein distention Tetanic contractions Polyuria
Jugular vein distention Explanation: SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 259.
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? Respiratory acidosis Respiratory alkalosis Metabolic alkalosis Metabolic acidosis
Metabolic acidosis Explanation: Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 284. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 284
The client's 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? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis Explanation: 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.
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
Metabolic alkalosis Explanation: Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma bicarbonate concentration. The most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.
The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? Neurological system Musculoskeletal system Endocrine system Gastrointestinal system
Neurological system Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Calcium Deficit (Hypocalcemia), p. 273.
Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. Administer the ordered potassium 40 mg IV push. Monitor intake and output every shift. Administer the ordered furosemide 60 mg po. Offer a diet with fruit juices and citrus fruits. Administer the ordered Kayexalate enema.
Offer a diet with fruit juices and citrus fruits. Monitor intake and output every shift. Explanation: Hypokalemia is a potassium level less than 3.5 mEq/L. Nurses must have knowledge of this life-threatening imbalance. The nurse would complete appropriate interventions such as offering a diet containing sufficient potassium, which includes fruits and vegetables, and monitoring the intake and output. Approximately 40 mEq of potassium is lost for every liter of urine output. Potassium is never administered via IV push; if IV potassium is needed, it is administered via infusion pump and with careful monitoring (e.g., EEG, BUN/creatinine, urine output) to ensure hyperkalemia does not result. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, Preventing Hypokalemia, p. 270.
A nurse in the Medical ICU has orders to infuse a hypertonic solution into a patient with low blood pressure. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. What term or terms are associated with this process? Osmosis and osmolality Active transport Diffusion Hydrostatic pressure
Osmosis and osmolality Explanation: Osmosis is the movement of fluid from a region of low solute concentration to the region of high solute concentration across a semipermeable membrane. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. Giving a patient who has low blood pressure a hypertonic solution will increase the number of dissolved particles in the blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move, so diffusion should not be normally taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.
A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply. Tender area around the insertion site Reddened area along the path of the vein Ecchymosis at the insertion site Cool area around the insertion site Rapid, shallow respirations
Reddened area along the path of the vein Tender area around the insertion site Explanation: Phlebitis is inflammation of a vein and is characterized by a reddened, warm area around an insertion site or along the path of a vein. The involved area is also tender and swollen. The nurse assesses infusion sites and determines the proper action to take. If indications lead to suspected phlebitis, the nurse will discontinue the intravenous line and restart with a different vessel. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Phlebitis, p. 292.
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 fall in pH? The lungs have ineffective cilia from years of smoking. The lungs are unable to exchange oxygen and carbon dioxide. The lungs are unable to breathe in sufficient oxygen. The lungs are not able to blow off carbon dioxide.
The lungs are not able to blow off carbon dioxide. Explanation: 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.
The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated. c. 0.45% NS b. 5% DW a. 0.9% NaCl d. 3% NS
b. 5% DW Explanation: A solution of D5W is an isotonic IV solution that is contraindicated in head injury because it may increase intracranial pressure.
A client with mild fluid volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this client? furosemide hydrochlorothiazide bumetanide torsemide
hydrochlorothiazide Explanation: Generally, thiazide diuretics, such as hydrochlorothiazide (HydroDIURIL) or chlorthalidone (Thalitone), are prescribed for mild to moderate hypervolemia and loop diuretics for severe hypervolemia. Thiazide diuretics block sodium reabsorption in the distal tubule, where only 5% to 10% of filtered sodium is reabsorbed. Loop diuretics, such as furosemide (Lasix), bumetanide (Bumex), or torsemide (Demadex), can cause a greater loss of both sodium and water because they block sodium reabsorption in the ascending limb of Henle's loop, where 20% to 30% of filtered sodium is normally reabsorbed.
A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: hyperkalemia. hypernatremia. hypokalemia. hypercalcemia.
hyperkalemia. Explanation: Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. Administering glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.
A client is experiencing edema in the tissue. What type of intravenous fluid would the nurse expect to be prescribed? no intravenous solution isotonic fluid hypotonic solution hypertonic solution
hypertonic solution Explanation: A hypertonic solution is used to pull water back in to circulation, as it has more particles than the body's water. If hypertonics are given too rapidly or in large quantities, they may cause an extracellular volume excess and precipitate circulatory overload and dehydration. As a result, these solutions must be given cautiously and usually only when the serum osmolality has decreased to dangerously low levels. Hypertonic solutions exert an osmotic pressure greater than that of the extracellular fluid. The hospitalized client requires treatment for the tissue edema. 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Table 13-5: Selected Water and Electrolyte Solutions, p. 261. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 261
