Fluid and Electrolyte, Acid/base, Burns HURST Q-card

The emergency department nurse is monitoring a client being admitted in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? Select All That Apply 1. pH 7.32 2. PaCO2 32 3. HCO3 25 4. PaO2 78 5. SaO2 82

1 &2. DKA, the client is acidotic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA. Normal PaCO2 is 35-45. Remember CO2 is considered an acid. The client in DKA will have an increased respiratory rate, so the PaCO2 will either be normal or low. This value of 32 is low and is an expected finding as the body is compensating for the acidosis.

A client who had a cerebral vascular accident (CVA) is now having Cheyne-Stokes respirations ranging from 12-30 breaths/minute. BP 158/108, HR 46. Based on this assessment, which acid/base imbalance does the nurse anticipate that this client will develop? Choose One 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Correct: Causes of respiratory acidosis include any causes of decreased respiratory drive, such as drugs (narcotics) or central nervous system disorders. With a massive cerebral vascular accident (CVA or stroke), the respiratory center in the brain is impaired and affects oxygenation. Cheyne-Stokes respirations are characterized by progressively deeper and sometimes faster respirations followed by periods of apnea. This leads to acidosis and often times respiratory arrest.

A client, admitted to the surgical unit post left thoracotomy, is drowsy. Vital signs on admit are T 99.8ºF (37.6ºC), HR 94, R 16/shallow, BP 100/68. ABGs are pH 7.33, PCO2 48, HCO324. What action should the nurse initiate? Choose One 1. Have client take deep breaths. 2. Administer naloxone. 3. Tell the client to breathe faster. 4. Medicate for pain.

1. Correct: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2 the client needs to turn, cough, and deep breathe. Incentive spirometry can be provided to assist the client with this effort.

What sign/symptom would indictate to the nurse that a client has had an inhalation injury? Select All That Apply 1. stridor 2. Swallowing difficulty 3. Singed nasal hair 4. Blisters to upper arms 5. Wheezing

1., 2., 3., & 5. Correct: Substernal/intercostal retraction and stridor are bad signs. Remember you will see difficulty swallowing, singed nasal and facial hair, and wheezing.

A client presents to the emergency department (ED) with flu symptoms, fever, and chills. The nurse notes that the vital signs are: T 102.8°F (39.3°C), P 128, RR 30, B/P 154/88. ABG results are: pH-7.5, PaCO2 32, HCO3 23. What acid/base imbalance does the nurse determine that this client has developed? Choose One 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Correct: This client has a high fever. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. Here, the ABGs reflect respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal.

What information on burn prevention strategies should the nurse include when providing an education program at a community center? Select All That Apply 1. Have chimney professionally inspected every 5 years. 2. Clean the lint trap on the clothes dryer after each use. 3. Keep anything that can burn at least 1 foot (0.30 meters) away from space heaters. 4. Do not hold a child while holding a hot drink. 5. Home hot water heater should be set at a maximum of 120°F (48.8°C).

2., 4., & 5. Correct: Lint that accumulates in the lint trap of a dryer can cause a fire, so the lint trap should be cleaned after each use. A hot beverage can easily spill on a child by accident when trying to handle both the beverage and child at the same time. Home hot water heater should be set at a maximum of 120°F (48.8°C), especially when small children, the elderly, or diabetics are in the home.

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? Choose One 1. Leave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.

3. Correct: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Exhibit pH 7.35 PaCO2 30 mm Hg Bicarb 19 mEq/liter PaO2 89 mm Hg SaO2 90% Select All That Apply 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3., & 7. Correct. These ABG values indicate metabolic acidosis. The pH is normal, but it is on the acidosis side of normal at 7.35. Now, which other chemical says acidosis? Look at the bicarb; the bicarb is low, indicating acidosis so there's your match! The bicarb matches the pH. What chemical problem does the bicarb relate to - respiratory or metabolic? It's metabolic. Metabolic acidosis. Has compensation begun? Yes. The lungs are compensating for the metabolic acidosis by getting rid of CO2, which is an acid. Therefore, the PaCO2 is below the normal range of 35-45. Since the pH is normal, full compensation has occurred.

What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim? Choose One 1. Remove jewelry. 2. Wrap in a clean blanket. 3. Cover burns with clean, dry cloth. 4. Briefly soak burned area in cool water.

4. Correct: Although all options are correct, the priority is to stop the burning process. Just putting out the flames is not enough to stop the burning process. You need to apply cool water briefly (no more than 10 minutes) to soak the burn area. Any longer can cause extensive heat loss.

A client was admitted with reports of prolonged diarrhea. The client's admission potassium level was 3.3 mEq/L (3.3 mmol/L) and is receiving an IV of D5 ½ NS with 20 mEq KCL at 125 mL/hr. The UAP reports an 8 hour urinary output of 200 mL. The previous 8 hour urinary output was 250 ml. What should be the nurse's priority action? Choose One 1. Encourage the client to increase PO fluid intake. 2. Administer a supplemental PO dose of potassium. 3. Stop the IV potassium infusion. 4. Administer polystyrene sulfonate PO Submit

Rationale 3. potassium is excreted by the kidneys. If the kidneys are not working well, the serum potassium will go up! Since the urine output has decreased below 30 mL/hr, urinary output is not adequate. client could start retaining too much potassium. The priority action is stop the infusion

An elderly client with partial and full-thickness burns has begun receiving fluids at 600 ml/hour, as determined by the Parkland (Consensus) Formula. Based on the assessment data for the first four hours, what should the nurse report to the primary healthcare provider? vitals are normal Choose One 1. The cardiovascular system is becoming seriously overloaded 2. The speed of the IV should be reduced since CVP is now normal 3. The changes in vital signs indicate an expected response to fluids 4. The client is deteriorating because of age and extent of the burns

The purpose of infusing large amounts of fluid into burn victims during the first 24 hours is to help maintain perfusion until the body's physiology returns to normal functioning. . Most importantly, the CVP (central venous pressure) has increased to the normal range, indicating the fluid replacement is adequate at this time.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Exhibit pH: 7.30 PaCo2: 55 Bicarb: 25 Select All That Apply 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

this is Respiratory Acidosis. So, is there any compensation going on? No, not yet. The bicarb is still within normal limits. These values indicate uncompensated respiratory acidosis.

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? Exhibit pH 7.44 PaCO2 51 mm Hg Bicarb 31 mEq/liter PaO2 91 mm Hg SaO2 91% Select All That Apply 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

this is metabolic alkalosis. Has compensation begun? Yes. The PaCO2 is high. The lungs are attempting to compensate by holding on to carbon dioxide, an acid, to make the pH normal. Since the pH is normal, full compensation has occurred.

A client who has been given steroids for a prolonged period to treat asthma, reports dizziness, tingling of the fingers, and muscle weakness. What action should the nurse take first? Choose One 1. Determine current blood pressure 2. Connect client to a cardiac monitor 3. Administer oxygen 4. Obtain arterial blood gases

2. Correct. These symptoms are indicative of hypokalemia and metabolic alkalosis. What do steroids do to the body? Steroids make you retain sodium and excrete potassium. So, you could become hypokalemic. Low potassium levels cause an increase in the reabsorption of bicarb by the kidneys. That is why you sometimes see metabolic alkalosis with Cushing's disease and prolonged steroid use. What electrolyte imbalance do we see with metabolic alkalosis? It's hypokalemia. So, if you have a client who is hypokalemic then they may have muscle weakness, hypotension and life threatening arrhythmias. And we know when the potassium is messed up, we should always think about the heart first. Connect the client to the cardiac monitor. 1. Incorrect. The priority is going to be checking the heart rhythm because a low potassium can cause a life-threatening arrhythmia. 3. Incorrect. The symptoms are most likely due to low potassium levels. This could lead to life-threatening arrhythmias. How would you fix this problem? Yes, give potassium, not oxygen. 4. Incorrect. You can do this after you check the heart rhythm. The priority is going to be checking the heart rhythm because a low potassium can cause a life-threatening arrhythmia. If you missed this question, review your notes on page 18 of your student book.

A client arrives at the clinic with reports of persistent vomiting, weakness and leg cramps. The nurse notes that the client is irritable. BP 102/58, HR 108, RR 14. Based on this data, what acid/base imbalance does the nurse expect? Choose One 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Correct: Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis.

Which initial arterial blood gas (ABG) results would the nurse likely see in a client who has overdosed on acetylsalicylic acid (ASA)? Choose One 1. pH 7.50, PaCO2 42, PaO2 63, SaO2 91, HCO3 28 2. pH 7.32, PaCO2 36, PaO2 83, SaO2 95, HCO3 19 3. pH 7.28, PaCO2 28, PaO2 72, SaO2 90, HCO3 16 4. pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24

4. Correct: This ABG result indicates respiratory alkalosis. Initially, acetylsalicylic acid stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off CO2 and causing the pH to increase. Losing CO2 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO?2 and normal HCO?3.

A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests? Select All That Apply 1. Hematocrit 2. Albumin 3. Potassium 4. Creatinine 5. Magnesium

Rationale 1, 3, & 4. CORRECT. The physiology of the body changes significantly following a major burn. Hematocrit increases as the fluid from the vascular spaces leaks into the interstitial tissues. Because of lysis of cells, potassium is released into the circulation, leading to hyperkalemia. The kidneys are impacted by the decreased cardiac output as well as the myoglobin released by the lysed cells. This causes creatinine to become elevated.

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client? Choose One 1. Fluid volume excess 2. Cellular edema 3. Severe hypotension 4. Decreasing CVP

Rationale 1. Correct: Albumin is a hypertonic solution. This type of solution will draw fluid from the cell into the vascular space. This builds up the volume in the vascular space. Therefore, the nurse must watch for fluid volume excess. Hypertonic solutions are used in clients who have 3rd spacing, severe edema, or ascites.

A client is admitted to the cardiac floor in heart failure. The lung sounds reveal crackles bilaterally, and the BP is 160/98. The client has been on diuretics at home and the potassium level is 3.3 mEq/L (3.3 mmol/L). Which diuretic would the nurse anticipate being prescribed for this client to minimize potassium loss? Choose One 1. Spironolactone 2. Furosemide 3. Bumetanide 4. Hydrochlorothiazide

Rationale 1. Correct: The client's potassium level is low. Spironolactone is a potassium sparing diuretic which would cause the potassium to be retained.

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate? Select All That Apply 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Place on a spine board. 4. Connect to cardiac monitor. 5. Perform the rule of nines. 6. Apply cervical collar to neck.

Rationale 1., 2., 3., 4., & 6. Correct: You need to understand that high-voltage current of electricity damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, so we worry about organ failure. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. Remember, vessels, nerves, and organs can be damaged. The nurse needs to monitor vital signs frequently, especially those assessing the respiratory and cardiac systems, since we worry about organ damage. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Why place the client on a spine board and put a c-collar on? Contact with electricity can cause muscle contractions strong enough to fracture bones, or vertebrae. The force of the electricity can actually throw the victim forcefully.

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? Select All That Apply 1. PO Calcium 2. Rapid IV Push Calcium 3. Vitamin D 4. Sevelamer hydrochloride 5. Phosphate supplements

Rationale 1., 3., & 4. Correct: Since this client has hypocalcemia, PO Calcium replacement would be an appropriate treatment. Now, let's look at the others that are not as obvious. Vitamin D helps to improve calcium absorption, which will help increase the calcium levels. So, what is sevelamer hydrochloride and how will this help hypocalcemia? Well, it is a phosphate binder. And remember that we said if you bind the phosphorus, the phosphorus levels go down. And since phosphorus and calcium have inverse relationships, as the phosphorus levels go down, the calcium levels will go up!

A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would best indicate understanding of the teaching? Choose One 1. "The increased level of ADH will cause my potassium level to be too high." 2. "I will be retaining sodium and water due to the increased amount of aldosterone." 3. "I will be losing lots of fluid due to the hormonal imbalance I have." 4. "I will feel jittery and nervous due to the elevated thyroxine levels."

Rationale 2. Correct: Cushing's is a disease that results in increased secretion of aldosterone. Having too much aldosterone causes the client to be at risk for fluid volume excess (FVE) due to the increased retention of both sodium and water.

A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mEq/L (149 mmol/L). What action by the nurse would be most appropriate at this time? Choose One 1. Administer 3% NS at 150 mL/hr 2. Perform neurological assessment 3. Increase oral intake of sodium 4. Decrease fluid intake

Rationale 2. Correct: Did you recognize that the sodium level of 149 is too high? The normal sodium level is 135-145 mEq/L (135-145 mmol/L). Think about the testing strategy that we mentioned to you. Look for neuro changes when the sodium level is not within normal limits. The brain does not like it when the sodium level is messed up. So, performing a neurological assessment on this client would be important.

A client is admitted following a severe burn. What changes related to fluid status would the nurse anticipate? Select All That Apply 1. Fluid volume excess 2. Hypovolemia 3. Third spacing 4. Increased urine output 5. Low CVP 6. Increased urine specific gravity

Rationale 2., 3., 5., & 6 Correct: Causes of fluid volume deficit (hypovolemia) include loss of fluid from anywhere as well as third spacing of fluid that occurs with such things as burns. Burns can result in fluid loss from the burn area as well as the third spacing, which increases the risk for hypovolemia and shock. As the fluid volume decreases, the BP and CVP both decrease. Remember, less volume, less pressure. Also, when the fluid volume becomes depleted, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. You will see the urine specific gravity increase because the small amount of urine being produced will be very concentrated.

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? Select All That Apply 1. Liver function 2. Respiratory rate 3. Calcium levels 4. Deep Tendon Reflexes (DTRs) 5. Urinary output

Rationale 2., 4., & 5 Correct: As you learned, magnesium acts like a sedative. Since we know that magnesium can cause respiratory depression, the nurse should always have a baseline respiratory assessment prior to initiating an infusion of magnesium. Muscle tone and DTRs can also become depressed, so a baseline assessment of DTRs would be very important. How is magnesium excreted? That's right! Through the kidneys. The nurse should always assess kidney function and urinary output prior to and during IV magnesium administration because of the risk of magnesium toxicity if it is being retained.

The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? Select All That Apply 1. Broiled, fresh fish 2. Effervescent soluble medications 3. Seasoning with lemon pepper 4. Chicken noodle soup 5. Deli-ham sandwiches

Rationale 2., 4., & 5. effervescent soluble medications and canned/processed foods should be avoided because they all contain a lot of sodium which increases fluid retention. Therefore, the chicken noodle soup and the cold cut deli-ham sandwiches should be avoided.

An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? Choose One 1. Guillian Barre 2. Severe dehydration 3. Advanced influenza 4. Carbon monoxide poisoning

Rationale 4. CORRECT. Carbon monoxide is a colorless, odorless, tasteless gas which permeates the blood stream, displacing the oxygen in hemoglobin. Symptoms are often confused with other illnesses, such as the flu. Assuming exposure is not fatal, the client may also experience extreme weakness, dizziness and blurred vision with confusion. Additionally, the carbon monoxide will cause lips and skin to become red in color. Without treatment, the client will die.

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? Choose One 1. Low serum hematocrit 2. High serum glucose 3. High urine protein 4. Low urine specific gravity

Rationale 4. Correct: Diabetes insipidus is a condition that results from decreased ADH production. Therefore, the client will be diuresing large volumes of water which leads to a fluid volume deficit. We worry about shock in these clients. Keep in mind that concentrated makes #s go up and dilute makes #s go down in reference to specific gravity, sodium, and hematocrit. Here, the urine is very dilute which means the urine specific gravity will be low.