Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances

A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?

Check the patient's blood pressure.

A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?

Assign the patient to a room near the nurse's station.

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

Auscultate the patient's breath sounds.

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

Administer the prescribed normal saline bolus and insulin.

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

Blood pressure is 90/40 mm Hg.

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?

Daily alcohol intake

A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

Daily weight

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved?

Decreased peripheral edema

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?

Digoxin (Lanoxin) 0.25 mg/day

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

Edema

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

Encourage fluid intake up to 4000 mL every day.

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?

Flush a saline lock with normal saline.

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

Give the patient the PRN IV morphine sulfate 4 mg.

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

Infuse 5% dextrose in water at 125 mL/hr.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

Lung sounds

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

Mental status

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

Metabolic acidosis

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?

Monitor ionized calcium level.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

Na+ 154 mEq/L (154 mmol/L)

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?

Notify the patient's health care provider.

After receiving the change-of-shift report, which patient should the nurse assess first?

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete?

Presence of the Chvostek's sign

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

Respiratory alkalosis

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

There are crackles throughout both lung fields.

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

Use the push-pause method to flush the CVAD after giving medications.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?

Suggest that the health care provider order a basic metabolic panel.

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

The patient is experiencing laryngeal stridor.

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?

"Increase fluids if your mouth feels dry."

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

The patellar and triceps reflexes are absent.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?

"I will drink apple juice instead of orange juice for breakfast."

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?

"The hypertonic solution will be more rapidly diluted when given through a central line."

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

Gradually decreasing level of consciousness (LOC)

IV potassium chloride (KCl) 60 mEq is prescribed for the treatment of a patient with severe hypokalemia. Which action should the nurse take?

Infuse the KCl at a rate of 10 mEq/hour.

During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?

Risk for injury: seizures

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

Serum calcium is 18 mg/dL.

A patient who has a small cell carcinoma of the lung develops a syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?

Serum sodium level of 120 mg/dL

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?

Skim milk