Module 4 EAQ practice

Normal sodium level

135-145 mEq/L

catheter embolism

Bluish coloring of the skin, increased heart rate, and low blood pressure indicates hypotension. These symptoms together with confusion indicate a catheter embolism, which occurs due to a blockage of the blood vessel from a portion of the IV catheter that broke.

The nurse is assessing a patient who is receiving intravenous (IV) therapy. The patient has developed phlebitis and reports pain with erythema. Which grade on the phlebitis scale of severity does the nurse assign the patient?

Grade 2

Donor blood must be screened for which three infections?

HIV, syphilis, and hepatitis C

The nurse is reviewing the laboratory results for a patient with hyperaldosteronism. Which electrolyte value does the nurse expect to find in the patient's diagnostic reports?

Hyperaldosteronism disrupts the regulation of potassium, thus leading to hypokalemia

A patient has had chronic diarrhea for 3 months. He also suffers from repeated bouts of vomiting. A nurse is reviewing the patient's laboratory report. What is a possible finding in the laboratory study report?

Serum K+ levels of less than 3.5 mEq/l

What should be monitored in patients with hyponatremia?

Serum osmolarity

1+ edema

Slight indentation (2 mm); mild indentation returns to normal fairly quickly

What fluids would be used to correct extracellular volume depletion and cellular dehydration?

Sodium chloride solutions of 0.225% and 0.45% are hypotonic in nature and are used to correct both extracellular volume depletion and cellular dehydration. These solutions have an effective osmolality lower than body fluids, which helps to move water into cells.

When would you use solutions of 3% and 5% sodium chloride?

Solutions of 3% and 5% sodium chloride are hypertonic and they aggravate cellular dehydration.

What are the symptoms of speed shock?

Sudden onset of dizziness, headache, facial flushing, and irregular heartbeat can occur as a result of speed shock; therefore, the nurse stops the medication administration if dizziness occurs.

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO 2, 21 mm Hg; PaO 2, 92 mm Hg; and HCO 3 -, 8. The nurse interprets these laboratory values to indicate:

The low pH indicates acidosis. The low PaCO 2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO 3 - indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus metabolic acidosis is the correct interpretation.

Which veins are commonly used for peripheral intravenous (IV) therapy in adults?

The metacarpal, median cubital, and cephalic veins are commonly used for peripheral IV therapy in adults, as they are larger in diameter and reduce the risk of hematomas.

What does the nurse teach the patient with a sodium level of 120 mEq/L?

The normal range of sodium levels are 135 to 145 mEq/L; therefore, a sodium level of 120 mEq/L indicates that the patient has hyponatremia. The nurse can instruct the patient to eat sodium-rich foods such as cured meat and cheese.

Hypophosphatemia

a phosphate level of 1.5 mEq/L

Hypomagnesemia

a serum magnesium level lower than 1.3 mEq/L.

A nurse is examining a patient with hypocalcemia. Which clinical findings should the nurse watch for during the assessment?

positive Chvostek's sign.; Trousseau's sign refers to the carpal spasm in response to hypoxia. This sign is positive in hypocalcemia. In addition, muscle twitching and cramping can be noted.

When is a NS solution of 0.9% used?

reestablish normal extracellular fluid levels in patients with hypovolemia and is isotonic.

Clinical manifestations of Hypomagnesium

seizures, mood swings, tachyarrhythmia

A nurse is learning about fluid, electrolyte, and acid-base balance. Which clinical findings would the nurse evaluate in a patient with hypomagnesemia?

seizures. Muscle cramps, twitching, and hyperactive deep tendon reflexes because low serum magnesium levels increase neuromuscular excitability

Which parameter does the nurse monitor to ensure the safety of a patient who presents with hyperphosphatemia?

serum creatinine levels; Hyperphosphatemia occurs when a patient is in renal failure, which increases the serum creatinine level.

A patient develops acute hemolytic transfusion reaction following transfusion with incompatible blood. What treatment strategies should be included in the patient's management?

stop transfusion immediately; Remove and replace tubing, flush with normal saline; send blood and urine to the lab; document reaction. Keep IV line open.

What is Chvostek's sign?

the contraction of facial muscles when a facial nerve is tapped.

what is osmosis

the movement of water molecules across semi-permeable membranes.

what is diffusion

the passive movement of electrolytes down the concentration gradient.

what is active transport

the transportation of electrolytes against the concentration gradient via adenosine triphosphate (ATP).

Phlebitis grade 1

there will be just pain and erythema.

Phlebitis grade 2

there will be pain, erythema, and edema.

Phlebitis grade 4

there will be pain, erythema, edema and purulent discharge

Signs of hyponatremia

usually presents with nausea, vomiting, confusion, and seizures. Hypermagnesemia is an abnormally high magnesium concentration in the blood.

Hypernitremia slow onset:

• Congestive heart failure • Renal failure • Increased sodium intake

Hypernitremia rapid onset:

• Severe vomiting • Hypertonic intravenous fluids • Excessive sweating

Interventions for Hypotonic fluid volume excess

Monitor vital signs Monitor intake and output Assess for neurologic changes Monitor laboratory results, especially hematocrit, BUN, and urine specific gravity

Hyponatremia

-When the sodium level is decreased in relation to body water; -serum level less than 135 mEq/L; -decreased concentration in the extracellular fluid, water moves into the cell, causing cellular swelling. -two kinds - hypovolemic and hypervolemic

The nurse is caring for a patient with an isotonic fluid volume deficit. Which types of intravenous solutions does the nurse expect the primary health care provider to prescribe?

0.9% normal saline solution is an isotonic intravenous solution that is used to reestablish normal extracellular fluid levels in patients with hypovolemia. D 5 0.45% normal saline solution is a hypertonic intravenous solution used to treat hypovolemia and normal fluid imbalances.

Fluid homeostasis in the body is maintained by fluid intake and absorption, fluid distribution, and fluid output. How much fluid does an average adult lose through feces?

200 mL (The fluid loss occurs through the skin, lungs, gastrointestinal tract, and kidneys. Even though the average fluid intake is 2500 mL, only 200 mL of fluid is lost through feces. The rest of the fluid is absorbed by the gastrointestinal system.)

Which IV needle works best for elderly patients?

A 24-gauge needle work best for elderly patients. An elderly patient who is dehydrated will have smaller veins, and the smaller needle will be easier to insert.

Which clinical manifestations does the nurse expect to find in a patient who has a febrile nonhemolytic reaction after receiving a blood transfusion?

A febrile nonhemolytic reaction is a reaction between the antibodies of the recipient and those from the blood donor's human leukocyte antigens. Chills and malaise are typical manifestations. A 2-degree (Fahrenheit) increase in body temperature is also commonly seen.

Hypoparathyroidism

A phosphate level of 2.8 mEq/L

Pulmonary edema

A rapid flow rate of IV solution can cause pulmonary edema. The manifestations of pulmonary edema are an increased pulse rate and increased blood pressure. The neck veins may also become distended, and crackles can be found in the lung bases.

When is D5 0.2% normal saline solution used?

A solution of D 5 0.2% normal saline solution is 5% dextrose and 0.2% sodium chloride; it is used for maintenance of fluids when a lower amount of sodium is required.

Crohn's disease

A type of inflammatory bowel disease that causes malabsorption in the intestines. This can lead to magnesium not being absorbed into the bloodstream, resulting in hypomagnesemia;

Hyperkalemia

Abnormally high potassium ion content in the blood; can be determined by assessing serum potassium levels; plasma potassium level greater than 5 mEq/L is diagnostic

steatorrhea

Acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This is called steatorrhea. This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids

Interventions for dehydration

Administer fluids Monitor vital signs Monitor intake and output Assess for neurologic changes Monitor laboratory results, especially hematocrit, BUN, and urine specific gravity

Interventions for hypovolemia

Administer fluids Monitor vital signs Monitor intake and output Monitor laboratory results, especially hematocrit, BUN, and urine specific gravity

How much fluid is lost daily through the skin (including perspiration) in a healthy adult?

Approximately 500 ml

Which electrolyte imbalance does the nurse suspect in a patient with diabetic ketoacidosis? a. Hypokalemia b. Hyperkalemia c. Hypocalcemia d. Hypercalcemia

B. Hyperkalemia

Normal phosphate level

Between 1.7 and 2.6

Hypertonic fluid volume deficit (dehydration)

Causes: Diabetes insipidus, diabetic ketoacidosis; administration of osmotic diuretics, hypertonic enteral tube feedings, or hypertonic intravenous fluids; prolonged vomiting and diarrhea Manifestations: Similar to hypovolemia, dry sticky mucous membranes, flushed dry skin, increased body temperature, irritability, convulsions, and coma

Hypotonic fluid volume excess

Causes: Excessive water intake, prolonged use of hypotonic IV solutions, SIADH Manifestations: Symptoms similar to isotonic fluid volume excess plus neurologic changes that indicate cerebral edema, including decreased level of consciousness, coma, and convulsions

Isotonic fluid volume deficit (hypovolemia)

Causes: Hemorrhage, burns, vomiting, diarrhea, Addison disease, fever, excessive perspiration Manifestations: Confusion, thirst, dry mucous membranes, orthostatic hypotension, tachycardia, weak and thready pulse, decreased skin turgor, prolonged capillary refill, and decreased urinary output

Which patient being cared for by the nurse is at the highest risk of developing respiratory acidosis?

Chronic respiratory acidosis is most commonly caused by COPD.

Signs of hypermagnesemia

Chvostek's sign and Trousseau's sign

Which nursing interventions are included in a patient's care plan to prevent an air embolism during intravenous (IV) therapy?

Clamp IV cath when changing the tube; prime all IV tubing with solution

A patient is dehydrated and needs an infusion of isotonic fluids to correct the condition. Which intravenous fluid is appropriate for the patient?

D5% in water; (D 5W) is an isotonic fluid. It enters cells rapidly, leaving free water, which dilutes extracellular fluid; most of the water then enters cells by osmosis. This mechanism helps correct dehydration

4+ edema

Deep indentation (8 mm); indentation remains several minutes

2+ edema

Deeper indentation (4 mm); indentation lasts longer

What should be monitored in patients with hypomagnesemia?

Dysphagia and delusions

What is the most reliable tool for determining potassium imbalances?

ECG

A patient presents with muscle twitching and cramping. On examination, the healthcare provider diagnoses the patient with calcium deficiency. What dietary instructions should the nurse give to this patient?

Hypocalcemia, or low levels of calcium, can manifest as muscle twitching and cramping. The signs and symptoms can be treated by providing adequate calcium in the diet. Vitamin D facilitates the absorption of calcium from the intestines; therefore, vitamin D should be supplemented in the diet.

A patient has had chronic diarrhea for 3 months. He also suffers from repeated bouts of vomiting. A nurse sends the patient's samples for laboratory studies. The laboratory reports indicate hypokalemia. Which signs is the nurse likely to find on the patient during examination?

In hypokalemia, the patient experiences bilateral muscle weakness that begins in the quadriceps and ascends to the respiratory muscles. Signs of digoxin toxicity at normal digoxin levels are also seen.

A patient is suffering from a malignancy in which the malignant cells secrete chemicals similar to parathyroid hormone. What does the nurse interpret about the patient's condition?

Increased levels of parathyroid hormone may cause shifting of the calcium from the bones to the extracellular space, leading to hypercalcemia.

When is a NS solution of 3% used?

Is a hypertonic solution used to treat severe hyponatremia.

When is a NS solution of 0.45% used?

Is half the normal concentration (hypotonic); it is used for determining renal function and is not used as replacement therapy.

When would you use Lactated Ringer's and 0.9% sodium chloride?

Lactated Ringer's (LR) and 0.9% sodium chloride are isotonic and correct only extracellular volume depletion.

While reviewing the diagnostic reports of a patient, the nurse finds that the sodium level is 148 mEq/L, the potassium level is 4.8 mEq/L, the calcium level is 6.5 mg/dL, and the magnesium level is 1.1 mEq/L. What does the nurse infer from these findings?

Low calcium levels; A calcium level of 6.5 mg/dL indicates that the patient has hypocalcemia; normal calcium levels range from 8.5 to 10.5 mg/dL

The nurse is caring for a patient whose phosphate level is 1.6 mEq/L. Which food does the nurse expect to be included in the patient's diet plan?

Milk

Interventions for Isotonic fluid volume excess

Monitor vital signs Monitor intake and output Assess for edema and JVD Auscultate lung fields Monitor laboratory results, especially hematocrit, BUN, and urine specific gravity

What risk does the nurse anticipate in a patient with hypocalcemia who presents with muscle cramps?

Muscle cramps can progress to tetany and convulsions. Calcium ions contribute to normal nerve and muscle cell functioning. A decrease in calcium levels can lead to spontaneous generation of action potentials, which in turn cause muscle contraction.

What are normal magnesium levels?

Normal magnesium levels range from 1.3 to 2.1 mEq/L

What are normal potassium levels:

Normal potassium levels range from 3.5 to 5.0 mEq/L;

A healthcare provider is planning to transfuse a patient with a unit of packed red blood cells. Which solution should the healthcare provider hang with the transfusion?

Normal saline consists of 0.9% NaCl and is considered isotonic. Normal saline is used for replacement of fluid, sodium, and chloride. It is the only fluid used to begin or finish blood transfusions

3+ edema

Obvious indentation (6 mm); indentation lasts several seconds

A patient has developed circulatory overload. Which therapies should the nurse expect the patient to be prescribed?

Oxygen is helpful in reducing the dyspnea, cough, crackles, and rales associated with circulatory volume overload. Diuretics are helpful in reducing circulatory volume overload by facilitating salt and water excretion in the kidney.

A patient has a partial pressure of carbon dioxide (PaCO 2) of 30 mm Hg. What does this value indicate about the patient's condition?

PaCO2 is the measure of the partial pressure of carbon dioxide in the blood and measures how well the lungs are excreting carbon dioxide produced during cellular metabolism. The normal value ranges from 35 to 45 mm of Hg. The patient has a value lower than normal.

The nurse is caring for a patient who has an accumulation of fluids in the pleural cavity. The nurse understands that this fluid is transcellular fluid secreted by epithelial cells. Which bodily fluids are examples of transcellular fluids?

Peritoneal, synovial, and cerebrospinal (Transcellular fluids are secreted by epithelial cells. Fluid collection between the two layers of the peritoneum is an example of transcellular fluid. Fluid collection in the synovial space of a joint is secreted by the epithelial cells and is also an example of transcellular fluid. Cerebrospinal fluid is colorless fluid present in the brain and spinal cord and is an example of transcellular fluid.)

Signs of hypocalcemia

Positive Chvostek's sign, Trousseau's sign, and presence of tetany; Low levels of calcium may affect the excitability of the nerve and muscle cells, causing cramps and abnormal muscle movements.

extracellular fluid volume deficit

Postural hypotension occurs when there is extracellular fluid volume deficit and not with excess of extracellular fluid volume. Weight loss is observed when there is extracellular fluid volume deficit and not with excess extracellular fluid volume.

A patient is receiving treatment for chronic diarrhea. The nurse advises the patient to eat food items rich in potassium. What is the reason behind promoting a potassium-rich diet?

Potassium is required for normal functioning of smooth, skeletal, and cardiac muscles as it helps to maintain resting membrane potential.

A nurse is teaching a group of patients about the importance of fluid and electrolyte balance in a health awareness program. Which common causes of hypokalemia would the nurse educate the patients about?

This can occur in patients with diarrhea or repeated vomiting. Hyperaldosteronism can also cause hypokalemia.

What veins should you avoid for venipuncture in older adults?

Veins on the hands and feet because of the increased chances of thrombophlebitis.

Clinical manifestations of hypovolemia:

Vomiting and diarrhea cause a loss of fluids, which can result in hypovolemia. Clinical manifestations of hypovolemia are tachycardia and decreased skin turgor.

The arterial pH of a patient is 7.3. How should the nurse record this pH in the patient case record?

acidosis

The nurse is preparing a patient for blood transfusion. Which drugs should the nurse keep on standby for managing blood transfusion reactions?

antihistamines and corticosteroids

What is the normal range of pH for a human?

between 7.35 and 7.45.

When are 16-18 gauge needles used?

blood transfusions, for rapid infusion of fluids in patients with trauma, or for patients who have undergone surgery.

Manifestation of chronic heart failure

can cause extracellular fluid volume excess due to decreased renal output caused by elevated aldosterone.

Isotonic fluid volume excess

causes: Congestive heart failure, renal failure, and cirrhosis Manifestations: Weight gain, edema in dependent areas, bounding peripheral pulses, hypertension, JVD, dyspnea, cough, abnormal lung sounds

The nurse works in an acute care facility. Which patients should the nurse monitor for development of hypokalemia?

diarrhea, vomiting, and potassium-wasting diuretics

Which defining characteristics are consistent with fluid volume deficit?

dry mucus membranes, thready pulses, tachycardia

Assessment findings consistent with intravenous (IV) fluid infiltration include:

edema and pain; pallor and coolness

The nurse understands that various mechanisms in the body help move fluid from one compartment to another. Which transport mechanism is governed by oncotic and hydrostatic pressures?

filtration

what is filtration process

fluid movement in and out of capillaries, and is governed by hydrostatic and oncotic pressure within the vascular and interstitial space.

Extracellular fluid volume excess

fluid retention manifested as ankle edema and weight gain. The neck veins may feel full on palpation when the patient is in upright position.

The nurse assesses that a patient has tachycardia, increased body temperature, and decreased blood pressure. On further assessment, the nurse finds the patient's pulse rate to be weak on palpation. Which complication should the nurse expect to find in this patient based on these findings?

fluid volume deficit

When are 20-22 gauge needles used?

generally used for general and intermittent solutions.

A patient with uncontrolled diabetes mellitus has developed diabetic ketoacidosis. What is the most likely complication that this patient may suffer?

hyperkalemia

A patient is suffering from syndrome of inappropriate of antidiuretic hormone (SIADH) secretion. For which electrolyte disturbance should the nurse evaluate the patient?

hyponitremia due to excess retention of water from the kidney, which is disproportionate to salt retention

the nurse notices that the patient has lost 8% of the total body weight. Which abnormality does the nurse interpret from this finding?

indicates severe dehydration. Hypertonic loss of fluids indicates dehydration and causes severe consequences. The severity of dehydration is determined by the percentage of the patient's total body weight.

What does the HCO 3 value indicate?

kidney function.

What does the PACO 2 value indicate?

lung function; the bicarbonate

A nurse is caring for an 89-year-old patient. The patient is very weak and refuses to eat. When preparing to insert the IV line, which site should the nurse select first considering the patient's age?

most distal appropriate site on inner arm

Signs of Hypokalemia

muscular weakness and cardiac rhythm disturbances.

Hypocalcemia

occurs when serum calcium levels fall below 8.5 mg/dL. It occurs as a result of inadequate intake of calcium, lack of absorption, or excessive losses. Decreased serum calcium levels occur when calcium cannot be absorbed from the small intestine. A large portion (40%) of serum calcium is bound to plasma proteins. When the protein stores are decreased, as in malnutrition and cirrhosis, the level of unbound calcium increases, making it available to be excreted by the kidneys. Administration of loop diuretics can lead to increased calcium excretion.

Phlebitis grade 3

pain and has erythema at the access site. The nurse can observe streak formation over the vein, and the vein is palpable

You assess four patients. Which patient is at highest risk for the development of hypocalcemia?

pancreatitis (because calcium binds to undigested fat in their feces and is excreted. This is called steatorrhea)