Fluid, Electrolyte, and Acid-Base Balance: Chapter 39 (Taylor)

The student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?

"I received a blood transfusion in the United Kingdom." Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.

What commonly used intravenous solution is hypotonic?

0.45% NaCl is hypotonic, while normal saline and Lactated Ringer's are isotonic. 5% dextrose in 0.45% NaCl is hypertonic.

Which individual will take longer to sense thirst?

70-year-old. When adults older than 65 years of age were compared with younger adults, the plasma osmolarity at which the older group experienced thirst was increased, indicating an increased risk for development of a water deficit.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

An infant has considerably more total-body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits.

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?

Hyperphosphatemia. Calcium and phosphorus have a reciprocal relationship—if the calcium level is low, the phosphorus level would be high. A magnesium deficiency, not excess, may be accompanied by hypocalcemia. Sodium and potassium deficiencies are not typically associated with low calcium levels.

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

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

The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?

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

Which client has more extracellular fluid?

Newborns have more extracellular fluid than intracellular fluid.

When educating a client about foods that affect fluid balance, the nurse would advise the client to decrease:

Sodium (Na+) is the most abundant electrolyte in the extracellular fluid (ECF). Na+ regulates extracellular fluid volume; Na+ loss or gain is accompanied by a loss or gain of water. Potassium (K+) is the major intracellular electrolyte. Calcium (Ca++) is a major component of bones and teeth. Magnesium (Mg++) is the most abundant intracellular cation after potassium

A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse?

Spinach. Sardines, whole grains, and green leafy vegetables also provide calcium.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?

The renal system retains more water. When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.

Which client will have more adipose tissue and less fluid?

Women have a lower fluid content because they have more adipose tissue then men.

Which client would be a candidate for total parenteral nutrition?

a client with colitis and bloody diarrhea. Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing. A client with bloody diarrhea and colitis requires complete bowel rest.

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

calcium and phosphorus. The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances.

Potassium is needed for neural, muscle, and:

cardiac function. Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities. Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias.

During a blood transfusion, a client displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?

hemolytic transfusion reaction: incompatibility of blood product

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?

pH: 7.60; PaCO2: 64; HCO3: 42

The passageways of the kidney permit the urine to flow to the bladder and:

selectively reabsorb or secrete substance to maintain fluids and electrolytes.

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

"Let me refer you to the blood bank so they can provide you with information." Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be re-infused.

Which fluid should be administered slowly to prevent circulatory overload?

5% NaCl. When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% NaCl and 5% NaCl.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?

An implanted central venous access device (CVAD). Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels. Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?

IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first. IV tubings are not replaced after every solution is over or after every 12, 24, or 36 hours.

Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease?

Increased plasma levels of antidiuretic hormone lead to water excess. In addition to increased plasma levels of antidiuretic hormones, plasma levels of albumin decrease, so that the distribution of extracellular fluid changes, vascular volume decreases, and interstitial volume increases. Complications often lead to ascites. Complications from cardiac failure can be described as the secretion of aldosterone, and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess. Hyperkalemia and hypocalcemia are common, and metabolic acidosis occurs with renal failure. Complications associated to respiratory failure include a disruption of acid-base balance and a disruption in this organ's ability to excrete carbon dioxide; this causes the pH of the person's blood to fall.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?

Sodium is regulated by the renin-angiotensin-aldosterone system.

The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to:

The decreasing percentage of body fluid in older adults is related to an increase in fat cells. In addition, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

A nurse is caring for a client with dehydration. Which sign is observed in a client with dehydration? Select all that apply.

decreased skin turgor over sternum low urine output decreased blood pressure

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins. Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended.

The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.)

drinking milk infusion of intravenous solution vomiting urination

A nurse is providing care to a client with an ECF volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply.

orthostatic hypotension decreased urine output slow-filling peripheral veins

A client with renal disease requires IV fluids. It is important for the nurse to:

place the fluids on an electronic device. An IV electronic infusion device usefully and accurately regulates the infusion rate, especially if fluid administration must be watched very carefully, such as when infusing fluid to a renal client or when administering certain medications.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes. The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.

A woman age 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:

replacement of fluids for those lost from vomiting and diarrhea. The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.