Cue Cards on Fluids & Electrolytes, Acid/Base, and Burns

What are key safety considerations to prevent burns in the home?

- Turn pot handles towards the wall while cooking. - Set water heater no higher than 120°F. - Do not put hot items on a table cloth (risk for toddlers pulling the table cloth off the table). - Cover electrical sockets when not in use.

A nurse is planning discharge education for a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which instructions should the nurse include when teaching this client? SATA. 1. Limit fluid intake. 2. Report muscle cramping. 3. Measure intake and output. 4. Perform mouth care once a day. 5. Report weight gain of 2 pounds (0.9 kg) over 24 hours.

1., 2., 3. & 5. Correct: The nurse should advise the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) to limit fluid intake. In SIADH, excessive amounts of water are reabsorbed by the kidneys, creating potentially disastrous dilutional hyponatremia. Water must be restricted to prevent water intoxication. The nurse should advise the client diagnosed SIADH to report muscle cramping. Muscle cramping should be reported immediately to the primary healthcare provider because this sign could indicate hyponatremia, which can lead to seizures or coma. The nurse should advise the client diagnosed with SIADH to measure intake and output. Intake and output should be monitored carefully to assess the amount of fluid restriction needed. Weight gain of 2 pounds (0.9 kg) or more should be reported to the primary healthcare provider because this is an indication of fluid retention and increases the client's risk for fluid volume excess. 4. Incorrect: The nurse should teach the client to rinse the mouth frequently to keep mucous membranes moist during fluid restriction, not just once a day.

An intravenous infusion of 0.45% normal saline is prescribed at a rate of 1000 mL in 24 hours. The tubing has a drop factor of 15. How many drops per minute (gtts/min) are delivered? Round your answer to the nearest whole number.

24 hours equals 1440 minutes Dividing 1000 by 1440 equals 0.694 This is multiplied by the drop factor of 15 Multiplying 15 by 0.694 equals 10.41, which rounds to 10.

A patient weighing 155 lbs (70 kg) is admitted to the burn unit with second and third degree burns covering 40% total body surface area. Normal saline IV resuscitation is ordered at 4 mL/kg per percentage of total body surface area burned over the first 24 hours. How much fluid does the nurse calculate the patient will receive in 24 hours?

4 mL x 70 kg = 280 280 mL x 40 TBSA = 11,200 mL in the first 24 hours

A patient weighing 220 lbs received full-thickness burns to 40% of their total body surface area (TBSA) this morning at 0730. Use the Consensus (aka Parkland) Formula to calculate: a. fluid replacement for the first 24 hrs b. the amount to receive in the first 8 hrs c. the time the infusion will complete if it is now 1030 d. the flow rate for the infusion Formula: 4 ml of LR x (wt in kg) x (% TBSA burned)

4 ml x 100 kg x 40 = 16,000 ml/ 24 hrs a. 16,000 mL First 8 hrs → patient gets half of the 24 hr amount b. 8,000 mL The first 8 hrs is based on the time of the burn and not on the admission time. c. 1530 8,000 mL / 5 hrs = 1,600 mL/hr d. 1,600 mL/hr

A client is admitted from the emergency department to a medical unit. What acid-base imbalance do the lab values indicate? pH = 7.44 PaCO2 = 30 HCO3 = 20 1. Metabolic acidosis 2. Compensated metabolic alkalosis 3. Respiratory acidosis 4. Compensated respiratory alkalosis

4. Correct: The pH is normal but on the alkaline side of normal. The PaCO2 is also alkaline and matches the pH. So it's respiratory alkalosis, and its compensated because the pH is within normal range. 1. Incorrect: Because the pH is alkaline, so acidosis is not the problem. 2. Incorrect: Because the bicarb is acid meaning that the problem is not metabolic. 3. Incorrect: Because the pH indicates the problem is alkalosis.

What would a rapid rise in CVP indicate in your burn patient?

A rapid ↑ CVP jump may indicate you're overfilling the RA especially if you're using a central line. (Slow and steady is the way to go) CVP range: 2-6 mmHg

The body produces antibodies with what type of immunity?

Active immunity

What type of immunity takes 2-4 weeks to develop?

Active immunity

Which acid base imbalance is associated with salicylate toxicity?

Acute salicylate poisoning results in respiratory alkalosis because of the initial ↑ RR. Because salicylate is an acid, prolonged salicylate toxicity converts to metabolic acidosis.

How does the air flow in a negative pressure room?

Air from the room is vented directly outside of the building.

A patient is admitted with advanced cirrhosis. The nurse's assessment verifies an abdominal girth increase of 5 inches and a weight increase of 6 pounds since yesterday. What does this data tell you the patient has?

Ascites.

Too little ADH

Associated disease: DI Fluid volume: deficit Blood: concentrate Urine: dilute Remember: DI = DIuresis

Too much ADH

Associated disease: SIADH Fluid volume: excess Blood: dilute Urine: concentrate

What electrolyte is the primary concern with hyperparathyroidism?

Calcium (C+) Hyperparathyroidism = hypercalcemia

FVD is a complication of?

DI DM Shock Ascites Burns Addison's disease

What assessment findings would you expect in a burn patient 24 hrs post-burn?

Fluid volume: deficit CVP: ↓ HR: ↑ BP: ↓ Edema: massive 2° 3rd spacing UO: ↓

Isotonic solution

Goes into the vascular space and stays there. Examples: NS, LR, D5W, and D5 1/4 NS Uses: fluid replacement in N/V, burns, sweating, and trauma ALERT: NOT for use in pts w/ HTN, cardiac disease, or renal disease → can cause FVE, HTN, and/or hypernatremia

Hypotonic solutions

Goes into the vascular space and then shifts out into the cells to replace cellular fluid. They hydrate and do not cause HTN because they don't stay in the vascular space. Examples: D2.5W, 1/2 NS, and 0.33% NS Uses: in the pt with HTN, hypernatremia, renal or cardiac disease and needs fluid replacement because of N/V, burns, hemorrhage, etc. ALERT: watch for cellular edema because this fluid is moving out to the cells which can lead to FVD and ↓ BP

What are the IV solutions that can cause hypervolemia?

Isotonic and hypertonic solutions Isotonic solutions go into the vascular space and they stay there. Hypertonic solutions are volume expanders and they will draw fluid in.

What type of IV solution do you want to use for a burn patient?

Isotonic solutions (example: 0.9% NS) because it will go into the vascular space and stay there. ↑ Vascular volume ↑ BP ↑ CO

IV solution memory device

Isotonic → stay where I put hypOtonic → go Out of the vessel hypErtonic → Enter the vessel

Why would you want to increase fluids in the patient with hypercalcemia?

Kidney stones are primarily made of calcium (C+) and you want to prevent them from forming and/or growing larger. Also fluids can help flush them out.

What cardiovascular conditions will you see with metabolic acidosis?

Large drops in BP HF Cardiac arrest

If your patient is hooked up NG tube to suction, what acid base imbalance might occur?

Metabolic alkalosis as too much of the stomach acid is removed. In contrast, the lower intestine has a lot of base and diarrhea could lead to metabolic acidosis.

What is a major complication of burns? Hint: think myoglobin

Myoglobin in a byproduct of the broken down tissue and muscle from the burns (especially electrical burns. Since myoglobin is filtered through the kidneys it can clog the renal tubules (the filters) and cause renal failure. UO will be brown or red and the PCM will want to flush the kidneys by ordering fluids and then an osmotic diuretic such as mannitol (Osmitrol) to help the kidneys excrete the myoglobin. (Mannitol pulls fluid from the intracellular compartment instead of from the blood like a loop diuretic.)

S/S of FVD

Neck veins: flat & small Peripheral edema: absent CVP: ↓ Lung sounds: dry & clear UO: ↓ HR: ↑ BP: ↓ Wt: ↓

S/S of FVE

Neck veins: full & bounding Peripheral edema: present CVP: ↑ Lung sounds: wet & crackles UO: ↓ HR: ↑ BP: ↑ Wt: ↑

What two medications would you give your burn patient that will be receiving whirlpool therapy for wound debridement?

Pain medication and antibiotics. Debridement is very painful and analgesics should be given 30 min prior. Cross-contamination and infection are you're two biggest concerns.

Which interventions are appropriate to prevent respiratory acidosis? SATA. a. deep breathing exercises b. assessing the O2 sat q 4 hrs c. IS q 2 hrs d. ↑ HOB e. Administer O2 f. relaxation techniques

Remember: treat each choice as true or false. a. deep breathing exercises c. IS q 2 hrs d. ↑ HOB b. is a poor choice because it will not prevent (keyword in question) respiratory acidosis but instead, watch it progress. e. is ineffective because all the O2 in the world won't improve hypoventilation. f. is recommended for hyperventilation (respiratory alkalosis).

IGg provides which type of immunity?

Passive immunity since IGg is an immunoglobulin and will temporarily bolster immunity.

What types of patients would you put into reverse isolation?

Patients with ↓ WBC count or compromised immunity: chemotherapy patients burn patients leukemia aplastic anemia transplant patients

What conditions are associated with respiratory acidosis?

Pneumothorax Narcotics overdose Abdominal incisions COPD

Respiratory Alkalosis: what chemical is the problem and which chemical is helping compensate?

Problem chemical: CO2 Helping chemical: HCO3 and hydrogen (H+)

Respiratory Alkalosis: what organ is the problem and which organ is helping fix it?

Problem organ: the lungs Helping organ: the kidneys

A patient is admitted from the ED to the floor. What acid base imbalance do you expect? pH: 7.48 CO2: 38 HCO3: 30 a. metabolic alkalosis b. compensated metabolic alkalosis c. respiratory acidosis d. compensated respiratory acidosis

Remember: respiratory opposite, metabolic equal (ROME). pH range: 7.35-7.45 CO2 range: 35-45 HCO3 range: 22-28 A pH of 7.48 is ↑ so it's alkaline. A CO2 of 38 is within range. A HCO3 of 30 is ↑ so it's alkaline. a. metabolic alkalosis

How can you increase CO2 levels?

Re-breathe it.

The nurse is taking care of a patient with major partial thickness burns. Tobramycin 125 mg IVPB has been ordered. What is the priority lab assessment prior to administering this medication? a. Cr b. K+ c. Mg d. BUN

Remember: -mycin is an aminoglycoside. (With aminoglycosides your priority concerns are the ears and the kidneys.) a. Cr is the most specific indicator of renal fx. d. BUN is a byproduct of protein breakdown which will occur in a burn patient. Additional examples of aminogylcosides: gentamicin, tobramycin, amikacin, plazomicin, streptomycin, neomycin, and paromomycin.

How can hypermagnesemia be life threatening?

Remember: Magnesium acts like a sedative. HR: ↓ RR: ↓

Why would you put your hypomagnesemia patient on seizure precautions?

Remember: Magnesium acts like a sedative. If they are hypo- then they are not sedated. Hyper-excitable and muscles are tight & rigid and they have potential to have a seizure.

A patient is admitted with advanced cirrhosis. The nurse's assessment verifies an abdominal girth increase of 5 inches and a weight increase of 6 pounds since yesterday. What further assessment findings would you expect? Select all that apply (SATA). a. hypotension b. cool extremities c. bradycardia d. CVP 8 mm/Hg e. 4+/5+ radial pulses

Remember: advanced cirrhosis is associated with FVD & shock. What are the S/S of FVD & shock? a. hypotension b. cool extremities Normal CVP is 2-6 mm/Hg. Read the pulses like they are on a scale of 5 which is the bottom number.

The nurse is caring for a patient that's 14 hours post-op abdominoplasty. The patient is reporting discomfort and the nurse observes restlessness and shallow, slow respirations. HR: 92 RR: 10 BP: 164/94 The patient was medicated with 2 mg of morphine for pain 1 hr ago. The PCM orders a set of arterial blood gases. Which set of ABGs would you expect to find? a. pH 7.30, CO2 40, HCO3 29 b. pH 7.33, CO2 48, HCO3 25 c. pH 7.47, CO2 35, HCO3 29 d. pH 7.50, CO2 33, HCO3 22

Remember: anytime there is an abdominal surgery think of respiratory acidosis. pH range: 7.35-7.45 CO2 range: 35-45 HCO3 range: 22-28 A pH of 7.33 is ↓ so it's acidic. A CO2 of 48 is ↑ so it's alkaline. A HCO3 of 25 is within range. b. pH 7.33, CO2 48, HCO3 25

What patient safety precautions should you take with hyperparathyroidism?

Remember: calcium (C+) acts as a sedative. Side rails ↑ x2, bed low and locked, bedside table within reach, call light in reach, guest or sitter in the room to assist with ambulation, fall precautions, etc. Assessment: - Frequent V/S checks for ↓ HR and ↓ RR. - Apply a heart monitor for possible arrhythmias. - Assess for ↓ LOC.

A patient is admitted from the ED to the floor. What acid base imbalance do you expect? pH: 7.33 CO2: 32 HCO3: 20 a. metabolic acidosis b. compensated metabolic acidosis c. respiratory acidosis d. compensated respiratory acidosis

Remember: respiratory opposite, metabolic equal (ROME). pH range: 7.35-7.45 CO2 range: 35-45 HCO3 range: 22-28 A pH of 7.33 is ↓ so it's acidic. A CO2 of 32 is ↓ so it's alkaline. A HCO3 of 20 is ↓ so it's acidic. a. metabolic acidosis The lungs are blowing off CO2 which is partially compensating. It is not considered full compensation until the pH is within normal range.

A patient is admitted from the ED to the floor. What acid base imbalance do you expect? pH: 7.44 CO2: 30 HCO3: 20 a. metabolic acidosis b. compensated metabolic acidosis c. respiratory alkalosis d. compensated respiratory alkalosis

Remember: respiratory opposite, metabolic equal (ROME). pH range: 7.35-7.45 CO2 range: 35-45 HCO3 range: 22-28 A pH of 7.44 is within range. A CO2 of 30 is ↓ so it's alkaline. A HCO3 of 20 is ↓ so it's acidic. d. compensated respiratory alkalosis The kidneys are compensating for the body by getting rid of the base. (The pH is closer to alkaline so it's aligned with the alkaline number of the CO2 which is why this is respiratory and not metabolic.)

You are reviewing patient assignments with an LVN working on a medical floor with you. Which patient assignment is appropriate for the LVN? SATA. a. The patient with N/V and mild metabolic alkalosis b. The patient with chronic back pain admitted for pain mgmt c. The patient on-call to the OR for a scheduled total knee replacement d. The patient admitted 24 hrs ago with sickle cell anemia and dehydration e. The patient with a stage III decubitus ulcer requiring a dressing change f. The patient newly diagnosed with diabetes who needs assistance with diet planning

Remember: treat each choice as true or false. b. LVNs can perform pain mgmt c. LVNs can perform pre-op prep d. this patient has been here 24 hrs since admission and is past the crisis stage e. LVNs can perform wound care a. patients with acid base imbalance are considered unstable and should not be delegated to LVNs. f. LVNs cannot develop a teaching plan.

A patient with a long history of diabetes presents to the ED with a blood glucose of 400 mg/dL. Which lab values indicate diabetic ketoacidosis (DKA)? a. Sodium (Na+) 140 mEq/L b. ↓ urine specific gravity c. K+ 5.3 mEq/L d. CO2 48 e. pH 7.33

Remember: treat each choice as true or false. b. ↓ urine specific gravity c. K+ 5.3 mEq/L e. pH 7.33

What acid base imbalance develops with prolonged hypoxia?

Respiratory acidosis

If you are hyperventilating what acid base imbalance are you at risk for?

Respiratory alkalosis

What acid base imbalance might you be experiencing if you're having a panic attack?

Respiratory alkalosis

What are the early S/S of hypoxia?

Restlessness & tachycardia

FVE is a complication of?

SIADH Cushing's disease Hyperaldosternoism HF Renal failure Conn's disease

A patient is admitted with advanced cirrhosis. The nurse's assessment verifies an abdominal girth increase of 5 inches and a weight increase of 6 pounds since yesterday. What is your main concern in the patient with advanced cirrhosis?

Shock because there is FVD in the vascular space.

What are the lab values specific to fluid volume deficit (FVD)?

Sodium: ↑ Hematocrit: ↑ Urine specific gravity: ↑ Remember: concentrate makes these numbers go up and dilute makes these numbers go down

What are the lab values for fluid volume excess (FVE)?

Sodium: ↓ Hematocrit: ↓ Urine specific gravity: ↓ Remember: concentrate makes these numbers go up and dilute makes these numbers go down

How can heart failure cause hypervolemia?

The heart is: weak CO: ↓ Renal perfusion: ↓ UO: ↓ (So the volume stays in the vascular space)

Which patients require a negative pressure room?

The patient with TB (so we can protect ourselves from them).

What assessment findings would you expect with hyperparathyroidism?

Think: too much Ca+ → too much sedative DTR: ↓ Weak, flaccid muscles Arrhythmias LOC: ↓ HR: ↓ RR: ↓

What OTC medication is associated with metabolic alkalosis?

Too much alka seltzer

How can you evaluate if fluid replacement is adequate in a burn patient?

UO is the best indicator in a burn patient instead of daily weight because you're pushing a lot of fluid and doing it rapidly. If the patient has good UO then you know the kidney's are perfusing and fluid replacement is adequate.

Hypertonic solution

Volume expanders that will draw fluid into the vascular space from the cell. Examples ("packed with particles"): D10W, 3% NS, 5% NS, D5LR, D5 1/2 NS, D5NS, TPN, and albumin Uses: hyponatremia, 3rd spacing, severe edema, ascites, and burn victims ALERT: monitor BP, HR, and CVP for FVE and pulmonary edema in the ICU setting especially if on 3-5% NS

A patient is admitted with advanced cirrhosis. The nurse's assessment verifies an abdominal girth increase of 5 inches and a weight increase of 6 pounds since yesterday. What interventions should the nurse expect to see in this patient's plan of care? SATA. a. elevate head of bed to a Semi-Fowler's position b. monitor the color of urine and stools c. turn every 2 hours d. instruct about a 1200 calorie diet e. monitor creatinine levels daily

a, b, c, & e are correct. The client needs to have the head of the bed elevated in order to relieve the pressure of ascites off of the diaphragm. The client with ascites is in a fluid volume deficit (FVD) and has the risk for postural hypotension and falls. It is important to monitor for jaundice. When jaundice is present the urine may be dark brown and the stool light gray to tan color. The distended tissue with ascites is fragile and can breakdown. Remember that the problem is the loss of protein into peritoneal cavity. Protein is necessary for tissue repair. This lab level would indicate renal function that can occur due to shock. d. diet instructions should focus on low salt, not low calories.

A client arrives at the ED after sustaining a high-voltage electrical injury. Which interventions should the nurse initiate in the ED? SATA. a. assess entry and exit wound b. monitor vital signs c. monitor for myoglobinuria d. connect to cardiac monitor e. perform the rule of nines

a, b, c, d. are the correct interventions for the nurse to initiate when caring for a patient who has sustained a high-voltage electrical injury. Remember: electricity kills vessels, nerves, and organs. e. The rule of nines would not be used for an electrical injury. Visual examination is not predictive of burn size and severity with an electrical burn injury.

A nurse is caring for a client who was admitted with severe dehydration due to excessive vomiting. Which data noted by the nurse validates this diagnosis? a. urine specific gravity: 1.036 b. dry mouth c. bradycardia d. tachypnea e. postural hypotension f. distended neck veins

a, b, d, & e. are signs and symptoms indicating that a client is dehydrated (FVD). c. bradycardia is not seen with dehydration. f. the patient with fluid volume deficit will have flat neck veins.

Which short term goal is most appropriate for a client with depression who is facing long term rehabilitation? a. demonstrate increased interest in family visits. b. make realistic plans for coping with rehabilitation. c. assign meaning to the life events contributing to current depression. d. communicate with other clients about their problems.

a. a patient with depression likes to be alone, so an appropriate goal that can be realistically accomplished in a short time span is to have the client interested in increased family visits.

The nurse is assigned a client who is one day post-thyroidectomy. While taking the patient's blood pressure, their hands start to tremble and an arrhythmia is noted on auscultation. What safety precautions should you take? SATA. a. initiate seizure precautions b. monitor potassium (K+) level c. monitor BUN and Cr d. restrict fluids e. check for airway patency

a. initiate seizure precautions e. check for airway patency

Based on the following ABG results, what acid base imbalance does the nurse expect to see? pH: 7.35 O2: 95% CO2: 49 HCO3: 30 a. respiratory acidosis compensated b. respiratory acidosis partially compensated c. metabolic acidosis partially compensated d. metabolic acidosis partially compensated

a. respiratory acidosis compensated The pH is normal but is on the acidic side of normal. The CO2 is elevated, causing acid formation. The HCO3 is alkalotic and is increased to buffer the acid. The pH and CO2 match, so the original problem was respiratory acidosis, but compensation has occurred since the pH is now normal.

A patient is admitted with advanced cirrhosis. The nurse's assessment verifies an abdominal girth increase of 5 inches and a weight increase of 6 pounds since yesterday. What position should this client be placed in? a. supine b. Mid-Fowler's c. Trendelenburg d. lateral, left side

b. Mid-Fowler's Elevating the patient's head will help improve respirations and perfusion.

A client with asthma has been admitted to the emergency room with sustained burns to the upper torso, face, and neck as a result of a steam injury when a pressure cooker exploded at home. Which intervention is the nurse's priority? a. initiate high flow oxygen b. prepare for endotracheal intubation c. administer 1,000 ml of LR d. assess for LOC

b. is correct and intubation must be accomplished quickly while a tube can still be inserted. The burn clients neck and facial area may become edematous due to capillary permeability.

A nurse is caring for a patient who had abdominal thoracic surgery 16 hours ago. What interpretation should the nurse make based on the results of the client's arterial blood gases (ABGs)? pH: 7.32 O2: 93% CO2: 48 HCO3: 24 a. metabolic acidosis b. respiratory acidosis c. metabolic alkalosis d. respiratory alkalosis

b. respiratory acidosis pH range: 7.35-7.45 CO2 range: 35-45 HCO3 range: 22-28 The pH is 7.32 ↓ which means acidosis. The CO2 of 48 is ↑ which indicates a respiratory problem. The ABG results indicate that the client is in respiratory acidosis.

What should the nurse monitor for when caring for a client receiving an IV of 1/2 NS at 100 mL/hr? a. HTN b. FVD c. hypernatremia d. pulmonary edema

b. since 1/2 NS is a hypotonic solution. Monitor for cellular edema because the fluid is moving out to the cell which could lead to FVD and decreased blood pressure.

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the LPN? a. involve the client in care decision making. b. reinforce the teaching plan with the client's family. c. maintain fresh fluids at bedside. d. evaluate I & O for adequate fluid replacement.

b. the LPN can reinforce teaching.

The client has pustules on the arm from intravenous drug abuse. The microbiology laboratory informs the nurse that the client's cultures are growing methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? SATA. a. Implement droplet precautions immediately b. Inform the client to wear a mask when ambulating in the hall c. Instruct the client on the importance of hand hygiene d. Cover the pustules to prevent drainage e. Allow pustules to drain freely

c & d because it's important that the nurse implement these interventions in order to prevent the spread of infection.

Which client would the nurse monitor for the development of hypovolemic shock? SATA. a. Admitted with acute myocardial infarction (MI) b. Post-operative hip replacement with spinal anesthesia c. Diagnosed with Addisonian crisis d. A 10 year old with 40% Total body surface area (BSA) burns e. Admitted with severe vomiting and diarrhea

c, d, & e. are at risk for hypovolemic shock due to the loss of fluid or blood.

A patient is admitted with advanced cirrhosis. The nurse's assessment verifies an abdominal girth increase of 5 inches and a weight increase of 6 pounds since yesterday. What is your priority assessment? a. UO b. daily weight c. BP d. LOC

c. BP The BP will drop as there is less volume since fluid has moved to the vascular space. Less volume = less pressure. Less pressure means less perfusion and the brain and kidneys are affected first. 20 minutes of poor kidney perfusion is all that is needed to damage the kidneys permanently. Low BP is considered anything < 90/60. Remember: initial means first. Priority means what would you do if you could only do one thing. All the answers are possible, but this is the priority choice.

A patient is admitted to the ED after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? a. respiratory b. cardiac c. airway d. neuro

c. airway A fire in an enclosed area causes concern for CO poisoning. In addition, to the burns to the chest, there is the potential for airway damage.

A patient with a long history of diabetes presents to the ED with a blood glucose of 400 mg/dL. The patient states, "I feel so weak!" On assessment, the nurse notes muscle twitching and an increased respiratory rate. What acid base imbalance is this patient at risk for? a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. metabolic alkalosis

c. metabolic acidosis Uncontrolled diabetes → inadequate insulin to carry blood sugar to the cell → break down of fat → ketones → acidosis. This patient is going into diabetic ketoacidosis (DKA), which leads to metabolic acidosis. Muscle twitching is 2° ↑ K+ (the body tries to compensate for ketones by moving H+ into the cells which pushes K+ out) ↑ RR = Kussmaul's respirations (blowing off CO2 to get rid of the acid)

A new nurse asks the charge nurse for assistance in interpreting ABGs. What acid base imbalance should the charge nurse tell the new nurse these results indicate? pH: 7.5 O2: 94% CO2: 58 HCO3: 35 a. partially compensated metabolic acidosis b. partially compensated respiratory alkalosis c. partially compensated metabolic alkalosis d. partially compensated respiratory acidosis

c. partially compensated metabolic alkalosis pH range: 7.35-7.45 CO2 range: 35-45 HCO3 range: 22-28 The pH is 7.5 is ↑ which means alkalosis. The CO2 is 58 which is ↑. Greater than 45 is acidosis from too much CO2. The HCO3 is 35 which is ↑. A high bicarb level equals alkalosis. The HCO3 matches the pH as both indicate alkalosis.

A nurse arrives at the scene of a home fire along with local EMS to find a patient lying in the front yard. Burns are noted to the face, neck and chest. In what order should the nurse care for this client at the scene? a. start a large bore IV line b. cover the wound c. remove restrictive objects d. establish airway patency e. assess breathing f. administer 100% humidified oxygen g. soak burned area with cool water

d, e, f, g, c, b This is the correct emergency procedures at the burn scene. First, establish airway patency. Second, assess breathing. Third, administer 100% humidified oxygen. Fourth, soak burned area with cool water. Fifth, remove restrictive objects. Sixth, start a large bore IV line. Seventh, cover the wound.

Standard orders on the nurse's unit include an intravenous infusion of D5 1/4 NS 1000 mL with 20 mEq potassium chloride to run at 100 mL per hour. This IV solution would be appropriate for which client diagnosis? SATA. a. Addisonian crisis b. hypertension c. chronic renal failure d. Cushing's disease e. hypokalemia

d. Cushing's disease e. hypokalemia Patients with cramping, Cushing's disease, and hypokalemia are safe to receive normal saline with potassium chloride. a. those with Addison's disease can have hyperkalemia if they experience an Addisonian crisis due to lack of aldosterone. When aldosterone is not secreted, Na+ and H2O are released and K+ levels ↑ in response to the hyponatremia. b. patients with hypertension need a hypotonic solution which will not increase their BP. c. patients in chronic renal failure are retaining fluid and K+. They do not need more K+.

A patient has been unable to eat due to protracted vomiting. Which alterations in the ABGs would the nurse expect to find? a. pH: 7.40, CO2: 44, HCO3: 23 b. pH: 7.33, CO2: 35, HCO3: 18 c. pH: 7.28, CO2: 48, HCO3: 29 d. pH: 7.46, CO2: 35, HCO3: 28

d. The stomach as a lot of acid in it. So, if the client is vomiting a lot, then the client is losing acid. This will make the client alkalotic inside. Is this going to be a lung problem? No. So we are looking for ABGs that indicate that this client is in metabolic alkalosis. A pH of 7.46 is ↑ which indicates alkalosis. The CO2 is 35. The HCO3 is 28, which is high and indicates alkalosis.

Which S/S would concern the nurse if assessed in a patient post radical neck surgery? SATA. a. bradypnea b. flaccid muscle tone c. flushed and warm skin d. positive Trousseau's sign e. leg cramps f. decreased deep tendon reflexes

d. positive Trousseau's sign e. leg cramps A positive Trousseau's sign indicates that muscles are rigid and tight due to a low calcium level. Some of the parathyroids could have been removed resulting in hypocalcemia. Hypocalcemia will cause muscle twitching and painful muscle cramps.

How should the nurse interpret the ABG results of a patient admitted with dehydration? pH: 7.49 O2: 99% CO2: 29 HCO3: 23 a. metabolic acidosis b. respiratory acidosis c. metabolic alkalosis d. respiratory alkalosis

d. respiratory alkalosis pH range: 7.35-7.45 CO2 range: 35-45 HCO3 range: 22-28 Why? The pH is 7.49 which indicates alkalosis since it is ↑. Which other chemical says alkalosis? The CO2 of 29 is ↓ which indicates alkalosis. The HCO3 is normal. This means that the client is in respiratory alkalosis.

A client is admitted for treatment of fluid volume excess. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. PCM orders: Bedrest 2 g Na+ diet Spironolactone 25 mg PO q day Potassium Chloride (KCL) 20 mEq PO BID Lab values: Na+: 138 mEq/L K+: 5.4 mEq/L Ca+: 9.0 mg/dL Glucose: 108 mg/dL Which prescription would be of concern to the nurse? a. bedrest b. 2 g Na+ diet c. Spironolactone d. Potassium Chloride (KCL)

d. the patient has been prescribed spironolactone, a potassium sparing diuretic, so a KCL supplement is not necessary.