Ch. 13 Fluid, Electrolytes: Balance and Disturbances

The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer?

0.45% sodium chloride Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 282 Half-strength saline (0.45% sodium chloride) solution is frequently used as an IV hypotonic solution.

A client's potassium level is elevated. The nurse is reviewing the ECG tracing. Identify the area on the tracing where the nurse would expect to see peaks.

(On the smaller bump)

Which solution is hypotonic?

0.45% NaCl Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 261 Half-strength saline is hypotonic. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A 5% NaCl solution is hypertonic.

Which is considered an isotonic solution?

0.9% normal saline

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-year-old with diarrhea Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 264 Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.

Which of the following measurable urine outputs indicates the client is maintaining adequate fluid intake and balance?

A patient with a minimal urine output of 30 mL/hour A client with minimal urine output of 30 mL/hour provides the nurse with the information that the patient is maintaining proper fluid balance. Less then 30 mL/hour of urine output indicates dehydration and possible poor kidney function.

Which of the following measurable urine output recorded indicates the patient is maintaining adequate fluid intake and balance?

A patient with a minimal urine output of 50 mL/hour A client with minimal urine output of 50 mL/hour provides the nurse with the information that the patient is maintaining proper fluid balance. Less then 50 ml /hour of urine output indicates dehydration and possible poor kidney function.

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Acidic Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 283 Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.

The nurse notes that a patient's urine osmolality is 980 mOsm/kg. What should the nurse assess as a possible cause of this finding?

Acidosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 255 Normal urine osmolality is 200 to 800 mOsm/kg, so 980 mOsm/kg is elevated. Acidosis is a factor that increases urine osmolality. Fluid volume excess, diabetes insipidus, and hyponatremia are all factors that decrease urine osmolality.

When a client's ventilation is impaired, the body retains which substance?

Carbon dioxide Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 253 When ventilation is impaired, the body retains carbon dioxide (CO2) because the carbonic acid level increases in the blood. Sodium bicarbonate is used to treat acidosis. Nitrous oxide, which has analgesic and anesthetic properties, commonly is administered before minor surgical procedures. When ventilation is impaired, the body doesn't retain oxygen. Instead, the tissues use oxygen and CO2 results.

Which electrolyte is a major anion in body fluid?

Chloride

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?

Dark, concentrated urine

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply.

Distended neck veins Crackles in the lung fields Shortness of breath Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 290 Clinical manifestations of FVE include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?

Extracellular fluid volume deficit Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. A cause of this loss is hemorrhage.

Which factor increases blood urea nitrogen (BUN)?

Gastrointestinal bleeding

In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply.

Heart failure Pulmonary edema Renal impairment Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 289 Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries.

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Hypokalemia

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Increases arterial pH Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.

A client with a magnesium concentration of 2.6 mEq/L (1.3 mmol/L) is being treated on a medical-surgical unit. Which treatment should the nurse anticipate will be used?

Intravenous furosemide

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions?

Neurological system Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 273 A client with a calcium level of 4.0 mg/dL has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Potassium: 5.8 mEq/L Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 271 Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.

The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia? Select all that apply.

Tachypnea Weakness Lethargy Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 282 The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride concentration is accompanied by a high sodium concentration and fluid retention.

What clinical indication of hyperphosphatemia does the nurse assess in a patient?

Tetany Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 279 Tetany is a symptom of hyperphosphatemia. Bone pain, paresthesia, and seizures are associated with hypophosphatemia.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago. A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH?

The lungs are not able to blow off carbon dioxide. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 286 In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, it is the lungs ability to remove the carbon dioxide from the system. Although individuals with COPD frequently have a history of smoking, cilia is not the cause of the acidosis.

Which condition leads to chronic respiratory acidosis in older adults?

Thoracic skeletal change Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 286 Poor respiratory exchange as the result of chronic lung disease, inactivity, or thoracic skeletal changes may lead to chronic respiratory acidosis. Decreased renal function in older adults can cause an inability to concentrate urine and is usually associated with fluid and electrolyte imbalance. A poor appetite, erratic meal patterns, inability to prepare nutritious meals, or financial circumstances may influence nutritional status, resulting in imbalances of electrolytes. Overuse of sodium bicarbonate may lead to metabolic alkalosis.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 263 Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.

A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess:

Trousseau's sign.

What does the nurse understand is the primary method by which fluid volume is regulated?

Urine excretion

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?

Urine pH of 3.0 Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 256 Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.

Which of the following may be the first sign of respiratory acidosis in anesthetized patients?

Ventricular fibrillation Ventricular fibrillation may be the first sign of respiratory acidosis in anesthetized patients. Clinical signs in acute and chronic respiratory acidosis include sudden hypercapnia that can cause increased pulse and respiratory rate, mental cloudiness, dull headache or weakness.

A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the nurse's best answer?

active transport Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 253 Active transport is the physiologic pump that moves fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate for energy. Passive osmosis does not require energy for transport. Free flow is transport of water naturally. Passive elimination is a filter process carried out in the kidneys.

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment?

electrocardiogram (ECG) results Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 263 Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.

Early signs of hypervolemia include

increased breathing effort and weight gain Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259 Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.

Clients diagnosed with hypervolemia should avoid sweet or dry food because it

increases the client's desire to consume fluid. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 263 The management goal in hypervolemia is to reduce fluid volume. For this reason, fluid is rationed and the client is advised to take a limited amount of fluid when thirsty. Sweet or dry food can increase the client's desire to consume fluid. Sweet or dry food does not obstruct water elimination or cause dehydration. Weight regulation is not part of hypervolemia management except to the extent it is achieved on account of fluid reduction.

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

muscle weakness.

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?

third-spacing Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259 Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites. Pitting edema occurs when indentations remain in the skin after compression. Anasarca is another term for generalized edema, or brawny edema, in which the interstitial spaces fill with fluid. Hypovolemia (fluid volume deficit) refers to a low volume of extracellular fluid.

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching?

tingling sensation in the fingers Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 273 Tingling or numbness in the fingers is a symptom of hypocalcemia. Flank pain, polyuria, and hypertension are symptoms of hypercalcemia.

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?

weight

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction?

"I will not salt my food; instead I'll use salt substitute." Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 272 The client should avoid salt substitutes. The nurse must caution clients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

0.45% NaCl Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 261 Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level?

115 mEq/L

The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be

155 mEq/L (155 mmol/L) Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 265 The client is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium concentration >145 mEq/L (>145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen and dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement?

Administer small volumes of a hypertonic solution. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 266 In clients with normal or excess fluid volume, hyponatremia is usually treated effectively by restricting fluid with clients who are not neurologically impaired. When the serum sodium concentration is overcorrected (exceeding 140 mEq/L) too rapidly or in the presence of hypoxia or anoxia, the client can develop neurological symptoms. However, if neurologic symptoms are severe (e.g., seizures, delirium, coma), or if the client has traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. Incorrect use of these fluids is extremely dangerous, because 1 L of 3% sodium chloride solution contains 513 mEq (mmol/L) of sodium and 1 L of 5% sodium chloride solution contains 855 mEq (mmol/L) of sodium. The recommendation for hypertonic saline administration in clients with craniocerebral trauma is between 0.10 to 1.0 mL of 3% saline per kilogram of body weight per hour.

The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance?

An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 265 The 82-year-old client has three risk factors: advanced age, tube feedings, and diuretic usage (torsemide). This client has the highest risk for fluid and electrolyte imbalances. The 45-year-old client has the risk factor of surgery, the 79-year-old client has the risk factor of advanced age, and the 66-year-old client has the risk factors of age and the bile drain, but none of these are the client at the highest risk.

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Chest pain Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 291 Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults?

Dehydration Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259 The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances. Therefore, options A, C, and D are incorrect.

Hypokalemia can cause which symptom to occur?

Excessive thirst Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 269 If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine and excessive thirst. Potassium depletion depresses the release of insulin and results in glucose intolerance. Decreased sensitivity to digitalis does not occur with hypokalemia.

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?

Hypercalcemia Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 275 The normal reference range for serum calcium is 8.6 to 10.2 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringer's solution

Your client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

Metabolic acidosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 284 The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) minus (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.

The client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

Metabolic acidosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 284 The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) − (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply.

Reddened area along the path of the vein Tender area around the insertion site Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 292 Phlebitis is inflammation of a vein and is characterized by a reddened, warm area around an insertion site or along the path of a vein. The involved area is also tender and swollen. The nurse assesses infusion sites and determines the proper action to take. If indications lead to suspected phlebitis, the nurse will discontinue the intravenous line and restart with a different vessel.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant?

Serum potassium level of 3 mEq/L Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 268-269 A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause cardiac arrhythmias and asystole, it's the most significant finding. In a client with a potential fluid volume imbalance, such as from vomiting, the other options are expected but none are as life-threatening as hypokalemia. A BUN level of 29 mg/dl indicates slight dehydration. A serum sodium level of 132 mEq/L is slightly below normal but not life-threatening. A urine specific gravity of 1.025 is normal.

A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values: Sodium 134 mEq/L (134 mmol/L) Potassium 3.2 mEq/L (3.2 mmol/L) Chloride 111 mEq/L (111 mmol/L) Magnesium 1.1 mg/dL (0.45 mmol/L) Calcium 8.4 mg/dL (2.1 mmol/L) What fluid and electrolyte imbalance would the nurse relate to the client's findings?

hypomagnesemia Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 277 Magnesium, the second most abundant intracellular cation, plays a role in both carbohydrate and protein metabolism. The most common cause of this imbalance is loss in the gastrointestinal tract. Hypomagnesemia is a value less than 1.3 mg/dL (0.45 mmol/L). Signs and symptoms include muscle weakness, tremors, irregular movements, tetany, vertigo, focal seizures, and positive Chvostek's and Trousseau's signs.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

A client diagnosed with hypernatremia needs fluid volume replacement. What intravenous solution would be the safest for the nurse to administer?

0.45% sodium chloride Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 290 A hypotonic solution (half-strength saline) is the solution of choice and considered safer than 5% dextrose in water because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. An isotonic solution (0.9%) is not desirable as a supplement because it provides Na and CL.

The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining?

1 L

A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into convulsions or a coma. What is the level of serum sodium at which a client can experience these side effects?

114 mEq/L

At which serum sodium concentration might convulsions or coma occur?

130 mEq/L (130 mmol/L) Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 265 Normal serum concentration level ranges from 135 to 145 mEq/L (135-145 mmol/L). When the level dips below 135 mEq/L (135 mmol/L), hyponatremia occurs. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L (mmol/L) are within the normal range.

A client weighing 160 pounds (72.6 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss?

158 lbs (71.7 kg)

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of:

280 mOsm/kg. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 255 Serum osmolality can be estimated by doubling the serum sodium or using the formula: Na × 2 = glucose/18 + BUN/3. Therefore, the nurse could estimate a serum osmolality of 280 mOsm/kg by doubling the serum sodium value of 140 mEq/L.

The nurse knows which is the normal serum value for potassium?

3.5-5.0 mEq/L (3.5-5.0 mmol/L).

What percentage of potassium excreted daily leaves the body by way of the kidneys?

80

The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?

Active transport Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 251 Active transport requires the use of the body's energy molecule (ATP) to meet body needs for fluid and particle transport. Osmosis is the movement of body fluids through a semipermeable membrane that allows not all substances to pass through. Passive diffusion allows the movement of substances from an area of higher concentration to lower concentration. Facilitated diffusion has certain dissolved substances that require the assistance from a carrier module to pass through the semipermeable membrane.

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

An elevated hematocrit level Electrolyte imbalance Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 255 Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.

What foods can the nurse recommend for the patient with hyperkalemia?

Apples and berries Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 270 Sources of potassium include fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains (Crawford & Harris, 2011b).

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Arterial blood gas (ABG) analysis

A volume-depleted patient would present with which of the following diagnostic lab results?

BUN-to-creatinine ratio of 24:1 Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259 A BUN-to-serum creatinine concentration ratio greater than 20:1 is indicative of volume depletion. The other results are within normal range.

A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned?

Calcium Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 273 Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state?

Compensated respiratory alkalosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 The question states that the client has a history of acid-base disturbance. The nurse would first note that the pH has returned to close to normal indicating compensation. The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3 (normal: 22 to 27mEq/L) levels. In a respiratory condition, the pH and the PCO2 move in opposite direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low, also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).

The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L). The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving?

Discontinue the intravenous lactated Ringer solution. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 261 The lactated Ringer intravenous (IV) fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer solution contains more sodium than daily requirements, and excess sodium worsens fluid volume excess. Lactated Ringer solution also contains potassium, which would worsen the hyperkalemia.

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.

Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst

A nurse reviews the results of an electrocardiogram (ECG) for a patient who is being assessed for hypokalemia. Which of the following would the nurse notice as the most significant diagnostic indicator?

Elevated U wave Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 269 An elevated U wave is specific for hypokalemia. Flat or inverted T waves may also be present. The other tracings are consistent with hyperkalemia.

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply.

Extravasation Infection Hematoma Phlebitis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 291 Local complications of intravenous therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, febrile reaction, and infection.

Which nerve is implicated in the Chvostek's sign?

Facial Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 274 Chvostek's sign consists of twitching of muscles supplied by the facial nerve when the nerve is tapped about 2 cm anterior to the earlobe, just below the zygomatic arch.

Oral intake is controlled by the thirst center, located in which of the following cerebral areas?

Hypothalamus

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which?

Insensible fluid loss Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 254 Due to the high heat and humidity, geriatric clients are at a high risk for insensible fluid loss through perspiration and vapor in the exhaled air. These losses are noted as unnoticeable and unmeasurable. Those with respiratory deficits and allergies may be only able to be outside for a limited period. Those with cardiovascular compromise may need to alternate outdoor activities with indoor rest.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?

Jugular vein distention Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259 Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Lungs and kidney Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 284 The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Metabolic acidosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 284 This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?

Metabolic alkalosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 285 Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma bicarbonate concentration. The most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?

Potassium Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 268 The nurse should identify potassium: 2.2 mEq/L as critical because a normal potassium level is 3.5 to 5.0 mEq/L. Severe hypokalemia can cause cardiac and respiratory arrest, possibly leading to death. Hypokalemia also depresses the release of insulin and results in glucose intolerance. The glucose level is above normal (normal is 75 to 110 mg/dl) and the chloride level is a bit low (normal is 100 to 110 mEq/L). Although these levels should be reported, neither is life-threatening. The BUN (normal is 8 to 26 mg/dl) and creatinine (normal is 0.8 to 1.4 mg/dl) are within normal range.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

Which of the following is a function of calcitonin? Select all that apply.

Reduces bone resorption Increases urinary excretion of calcium Increases deposition of calcium in bones Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 276 Calcitonin reduces bones resorption, increasing deposition of calcium and phosphorous in the bones, and increases urinary excretion of calcium and phosphate.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

Serum sodium level of 124 mEq/L Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 266 In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated.

b. 5% DW Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 261 A solution of D5W is an isotonic IV solution that is contraindicated in head injury because it may increase intracranial pressure.

A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of:

b. Increased PaCO2. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 285 The respiratory system compensates by decreasing ventilation to conserve CO2 and increase the PaCO2.

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 137 mEq/L (137 mmol/L) potassium 4.6 mEq/L (4.6 mmol/L) chloride 94 mEq/L (94 mmol/L) calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is of highest concern to the nurse?

calcium 12.9 mg/dL (3.2 mmol/L) Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 275 More than 99% of the body's calcium is found in the skeletal system. Hypercalcemia, or calcium levels exceeding 10.2 mg/dL (2.5 mmol/L), can be a dangerous imbalance. The client presents with anorexia, nausea and vomiting, constipation, abdominal pain, bone pain, and confusion. The listed sodium, potassium, and chloride levels are within normal limits.

A client with emphysema is at a greater risk for developing which acid-base imbalance?

chronic respiratory acidosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 286 Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.

A nurse evaluates a client's laboratory results. What is a factor that may be affecting an increase in serum osmolality?

free water loss Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 255 Osmolality measures the solute concentration per kilogram in blood and urine. Water loss in the serum would increase the solute concentration. Free water loss is a factor increasing serum osmolality. Diuretic use, overhydration, and hyponatremia are factors decreasing serum osmolality.

A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed?

furosemide Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 263 Furosemide is the only loop diuretic choice. Hydrochlorothiazide and metolazone are thiazide diuretics that block sodium reabsorption. Spironolactone is a potassium-sparing diuretic that prevents sodium absorption.

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

hyperkalemia

A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia?

hypomagnesemia Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 278 If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.

Oncotic pressure refers to the

osmotic pressure exerted by proteins Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 253 Oncotic pressure is a pulling pressure exerted by proteins such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when urine output increases as a result of excretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.

A nurse is monitoring a client being evaluated who has a potassium level of 7 mEq/L (mmol/L). Which electrocardiogram changes will the client display?

peaked T waves Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 271-272 The earliest changes occur when the serum potassium level is 7 mEq/L (mmol/L). Cardiac tracings include peaked and narrow T waves, ST segment depression, and a shortened QT interval.

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?

In dehydration, only extracellular is depleted. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259 In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.

Which condition might occur with respiratory acidosis?

Increased intracranial pressure Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 286 If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.

A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client?

165 mEq/L

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be?

275-300 mOsm/kg Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 255 In healthy adults, normal serum osmolality is 270 to 300 mOsm/kg (Crawford & Harris, 2011c).

A patient is admitted with a diagnosis of renal failure. The patient complains of "stomach distress" and describes ingesting several antacid tablets over the past 2 days. Blood pressure is 110/70 mm Hg, face is flushed, and the patient is experiencing generalized weakness. Which is the most likely magnesium level associated with the symptoms the patient is having?

5 mEq/L Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 276 Magnesium excess (>2.7 mEq/L) is associated with the following symptoms: flushing, hypotension, muscle weakness, drowsiness, hypoactive reflexes, depressed respirations, and cardiac arrest. The respiratory center is depressed when serum magnesium levels exceed 10 mEq/L (5 mmol/L). This is not present in this patient, so the magnesium level is unlikely to be 11 mEq/L. Coma, atrioventricular heart block, and cardiac arrest can occur when the serum magnesium level is greatly elevated and not treated.

The nurse is caring for a patient with a metabolic acidosis (pH 7.25). Which of the following values is useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss?

Anion gap Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page p. 284 Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.

Which is an insensible mechanism of fluid loss?

Breathing Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 254 Loss of fluid from sweat or diaphoresis is referred to as insensible loss because it is unnoticeable and immeasurable. Losses from urination and bowel elimination are measurable. Nausea does not result in fluid loss, however if the client would develop emesis ( vomiting) this would be considered loss of body fluids and would need measured.

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.

Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 285 Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Confusion and seizures Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 261 Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

Elevated blood pressure

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?

Elevated hematocrit level Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259 When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

Extreme anxiety Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema?

Generalized There may be generalized edema in all the interstitial spaces, which sometimes is called brawny edema or anasarca. Options B and D are not part of the process of third-spacing fluid. Option C is a distractor for this question.

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

Hyperkalemia Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 269 Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination doesn't help reverse the effects of hypercalcemia, hypernatremia, or hyperglycemia.

The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte imbalance?

Hypocalcemia Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 275 The client is experiencing an elevated serum phosphorus concentration. Hyperphosphatemia is defined as a serum phosphorus that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus concentration tends to cause a low serum calcium concentration.

A patient has a serum osmolality of 250 mOsm/kg. The nurse knows to assess further for:

Hyponatremia. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 255 Decreased serum sodium is a factor associated with decreased serum osmolality. Dehydration and hyperglycemia are associated with increased serum osmolality; acidosis is associated with increased urine osmolality.

Which could be a potential cause of respiratory acidosis?

Hypoventilation Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 286 Respiratory acidosis is always due to inadequate excretion of CO2, with inadequate ventilation, resulting in elevated plasma CO concentration, which causes increased levels of carbonic acid. In addition to an elevated PaCO2, hypoventilation usually causes a decrease in PaO2.

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?

Instruct the client to breathe into a paper bag. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water?

Intracellular fluid Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 257 About 60% of the adult human body is water. Most body water is located within the cell (intracellular fluid). Due to several physiological changes of aging, geriatric clients have less bodily fluids.

With which condition should the nurse expect that a decrease in serum osmolality will occur?

Kidney failure Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 256 Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Headache, blurry vision, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance?

Metabolic acidosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 285 The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?

No, sodium intake should be restricted.

The calcium concentration in the blood is regulated by which mechanism?

Parathyroid hormone (PTH) Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 273 The serum calcium concentration is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium concentration in the blood.

Which electrolyte is a major cation in body fluid?

Potassium Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 252 Potassium is a major cation that affects cardiac muscle functioning. Chloride, bicarbonate, and phosphate are anions.

The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a client experiencing hypercalcemia. Which ECG change is typically associated with this electrolyte imbalance?

Prolonged PR intervals Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 276 Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium concentration.

A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant?

Provide oral care every 2-3 hours. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 268 Providing oral care for the client every 2-3 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?

Respiratory alkalosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.

What does the nurse recognize as one of the best indicators of the patient's renal function?

Serum creatinine Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 255 Creatinine is the end product of muscle metabolism. It is a better indicator of renal function than BUN because it does not vary with protein intake and metabolic state.

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Sodium

Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis?

Sodium bicarbonate Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 272 IV administration of sodium bicarbonate may be necessary in severe metabolic acidosis to alkalinize the plasma, shift potassium into the cells, and furnish sodium to antagonize the cardiac effects of potassium.

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators?

Sodium level of 150 mEq/L

Which of the following is a factor affecting an increase in urine osmolality?

Syndrome of inappropriate antidiuretic hormone release (SIADH) Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 264 Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and congestive heart failure. Myocardial infarction typically is not a factor that increases urine osmolality.

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition?

dehydration

Which set of arterial blood gas (ABG) results requires further investigation?

pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 The ABG results pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L indicate respiratory alkalosis. The pH level is increased, and the HCO3- and PaCO2 levels are decreased. Normal values are pH 7.35 to 7.45; PaCO2 35 to 45 mm Hg; HCO3- 22 to 26 mEq/L.

The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 284 Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.

An adult client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next?

Consider sodium restriction with discontinuation of salt tablets.

Which is a correct route of administration for potassium?

Oral Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 269-270 Potassium may be administered through the oral route. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. Potassium is not administered subcutaneously.

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching?

"I can use laxatives and enemas but only once a week." Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 269 The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives, diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, client education may help alleviate the problem.

A client weighing 160.2 pounds (72.7 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss?

158.0 lbs (71.7 kg) Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 260 A loss of 0.5 kg, or 1.1 lb, represents a fluid loss of about 500 mL. Therefore, a loss of 1,000 mL would be equivalent to the loss of 2.2 lbs (1 kg), bringing the client's weight to 158.0 lbs (71.7 kg).

A patient is admitted with severe vomiting for 24 hours as well as weakness and "feeling exhausted." The nurse observes flat T waves and ST-segment depression on the electrocardiogram. Which potassium level does the nurse observe when the laboratory studies are complete?

2.5 mEq/L Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 268-269 Symptoms of hypokalemia (<3.0 mEq/L) include fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria, decreased bowel motility, ventricular asystole or fibrillation, paresthesias, leg cramps, hypotension, ileus, abdominal distention, and hypoactive reflexes. Electrocardiogram findings associated with hypokalemia include flattened T waves, prominent U waves, ST depression, and prolonged PR interval.

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be

7.50 Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 287 The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is >7.45 and the PaCO2 is <38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, gram-negative bacteremia, and inappropriate ventilator settings.

It is important for a nurse to know how to calculate the corrected serum calcium level for a patient when hypocalcemia is seen along with low serum albumin levels. Calculate the corrected serum calcium when the serum calcium is 9 mg/dL and the serum albumin is 3 g/dL.

9.8 mg/dL Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 274 To calculate corrected serum calcium, subtract the normal serum albumin level of 4 g/dL from the reported albumin level of 3 g/dL, multiply that value (1) by 0.8 (constant factor) and then add that result (0.8 mg) to the reported serum level of 9 mg/dL. Therefore, 9 + 0.8 = 9.8 mg/dL (corrected value). Note: a constant factor of 0.8 is used because, for every decrease in serum albumin of 1 g/dL below 4 g/dL, the total serum calcium level is underestimated by 0.8 mg/dL.

Which of the following is the most common cause of symptomatic hypomagnesemia in the United States?

Alcoholism Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 277 Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Any disruption in small bowel function, as in intestinal resection or inflammatory bowel disease, can lead to hypomagnesemia.

Which is the most common cause of symptomatic hypomagnesemia?

Alcoholism Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 277 Alcoholism is currently the most common cause of symptomatic hypomagnesemia. Intravenous drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia.

The nurse is caring for a patient with a diagnosis of hyponatremia. What nursing intervention is appropriate to include in the plan of care for this patient? (Select all that apply.)

Assessing for symptoms of nausea and malaise Monitoring neurologic status Restricting tap water intake For patients at risk, the nurse closely laboratory values (i.e., sodium) and be alert for GI manifestations such as anorexia, nausea, vomiting, and abdominal cramping. The nurse must be alert for central nervous system changes, such as lethargy, confusion, muscle twitching, and seizures. Neurologic signs are associated with very low sodium levels that have fallen rapidly because of fluid overloading. For a patient with abnormal losses of sodium who can consume a general diet, the nurse encourages foods and fluids with high sodium content to control hyponatremia. For example, broth made with one beef cube contains approximately 900 mg of sodium; 8 oz of tomato juice contains approximately 700 mg of sodium. If the primary problem is water retention, it is safer to restrict fluid intake than to administer sodium.

A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply.

Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Urine specific gravity of 1.03 Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 255-256 Severe dehydration is associated with an increased BUN (N = 10 to 20 mg/dL), serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L) and urine specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would also be elevated but are within normal range for this question.

A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned?

Calcium Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 273 Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?

Cerebral edema Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 265 Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for?

Cerebral edema Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 268 Treatment of hypernatremia consists of a gradual lowering of the serum sodium level by the infusion of a hypotonic electrolyte solution (e.g., 0.3% sodium chloride) or an isotonic nonsaline solution (e.g., dextrose 5% in water [D5W]). D5W is indicated when water needs to be replaced without sodium. Clinicians consider a hypotonic sodium solution to be safer than D5W because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. It is the solution of choice in severe hyperglycemia with hypernatremia. A rapid reduction in the serum sodium level temporarily decreases the plasma osmolality below that of the fluid in the brain tissue, causing dangerous cerebral edema.

A client presents with severe diarrhea and a history of chronic renal failure to the emergency department. Arterial blood gas results are as follows: pH 7.30 PaO2 97 PaCO2 37 HCO3 18 The nurse would expect which of the following sets of assessment findings?

Clammy skin, blood pressure 86/46, headache Metabolic acidosis, a common clinical disturbance, is characterized by decreased pH and plasma bicarbonate concentration. Common causes of metabolic acidosis include diarrhea, chronic renal failure, use of diuretics, intestinal fistulas, and ureterostomies. The client will experience the following signs and symptoms: headache, confusion, increased respiratory rate, nausea, vomiting, cold and clammy skin, and decreased blood pressure.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

Confusion Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 265 Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply.

Cyanosis Shoulder pain Dyspnea Tachycardia Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 291 Hypotension, along with the other correct choices, is a manifestation of an air embolism. Crackles on auscultation is a major indicator of circulatory system overload.

The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?

Hypocalcemia Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 280 Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia.

When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up?

Irregular heart rate Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, confusion may occur with dehydration and hyponatremia, and blood pressure is slightly lower than normal (though not life threatening); in each case, following up on potential cardiac dysrhythmias is a higher priority.

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Jugular vein distention Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259 SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?

Limit sodium and water intake. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 263 Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely?

Magnesium Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 277 Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.

The client has stomach cancer and has been connected to continuous nasograstric suctioning to control nausea and vomiting. The following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Metabolic Acidosis

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?

Metabolic acidosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 284 Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg.

The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur?

Metabolic alkalosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 285 Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Metabolic alkalosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 288 A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

A priority nursing intervention for a client with hypervolemia involves which of the following?

Monitoring respiratory status for signs and symptoms of pulmonary complications. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 264 Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.

The nurse is caring for a client who was admitted with fluid volume excess (FVE). Which nursing assessments should the nurse include in the ongoing monitoring of the client? Select all that apply.

Nutritional status and diet Blood pressure, heart rate, and rhythm Intake and output, urine volume, and color Skin assessment for edema and turgor Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 263 To assess for FVE the nurse measures blood pressure, heart rate and rhythm, and breath sounds; inspects the skin to look for edema and turgor; and inspects neck veins. Intake and output, daily weight, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess. Treatment of FVE typically involves dietary restriction of sodium.

Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply.

Offer a diet with fruit juices and citrus fruits. Monitor intake and output every shift. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 270 Hypokalemia is a potassium level less than 3.5 mEq/L. Nurses must have knowledge of this life-threatening imbalance. The nurse would complete appropriate interventions such as offering a diet containing sufficient potassium, which includes fruits and vegetables, and monitoring the intake and output. Approximately 40 mEq of potassium is lost for every liter of urine output. Potassium is never administered via IV push; if IV potassium is needed, it is administered via infusion pump and with careful monitoring (e.g., EEG, BUN/creatinine, urine output) to ensure hyperkalemia does not result.

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?

Offer a prescribed antiemetic medication. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 262 When calculating the intake and output of a client, it is essential to understand that the normal average intake is 2500 mL in adults. Ranges are often noted at 1800 to 3000 mL. Because the client is vomiting, offering a prescribed antiemetic medication would decrease the output from emesis and increase the input as the client may be more accepting of oral fluids. The client should be encouraged more oral intake once vomiting has subsided, but if not possible, intravenous fluids should be increased to avoid dehydration A fluid restriction could cause dehydration. Removing the Hemovac will decrease documented output but may lead to an internal infection from fluid accumulation.

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.)

Oliguria Tachycardia Tachypnea Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 259 Hypovolemia, or fluid volume deficit, is indicated by decreased, not increased, blood pressure (hypotension), oliguria, tachycardia (not bradycardia), and tachypnea.

A patient with abnormal sodium losses is receiving a regular diet. How can the nurse supplement the patient's diet to provide 1,600 mg of sodium daily?

One beef cube and 8 oz of tomato juice Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 267 For a patient with abnormal losses of sodium who can consume a general diet, the nurse encourages foods and fluids with high sodium content to control hyponatremia. For example, broth made with one beef cube contains approximately 900 mg of sodium; 8 oz of tomato juice contains approximately 700 mg of sodium. The nurse also needs to be familiar with the sodium content of parenteral fluids (see Table 13-5).

A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance?

Presence of Trousseau sign Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 273-274 After radical neck resection, a client is prone to developing hypocalcemia. Hypocalcemia is defined as a serum value <8.6 mg/dL (<2.15 mmol/L). Signs and symptoms of hypocalcemia include Chvostek sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped; and a positive Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?

Pulse Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 272 An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client's pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing respirations and temperature because these aren't affected by the serum potassium level.

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

Respiratory acidosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 286 Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.

An elderly client with significant dementia is brought to Emergency Care triage stating that she believes people are invading her bedroom several times a night trying to take her purse. The caregiver is concerned about a stroke because the client complains of a constant tingling in her lips and fingertips. The client has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

Respiratory alklosis

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

Restricting fluids to 800 ml/day Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 266 Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.

The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action?

Send the client for a chest x-ray. A chest x-ray is needed to confirm the placement of catheter tip before initiating ordered infusions. Consent should be obtained before, not after, the procedure. No BPs should be taken on the extremity where the catheter is placed.

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Serum bicarbonate of 28 mEq/L Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 288 Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.

A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse?

bicarbonate-carbonic acid buffer system Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 284 The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system. The renin-angiotensin-aldosterone system regulates blood pressure. The sodium-potassium pump regulate homeostasis. The ADH-ANP buffer system regulates water balance in the body.

A client with mild fluid volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this client?

hydrochlorothiazide Loop diuretics, such as furosemide (Lasix), bumetanide (Bumex), or torsemide (Demadex), can cause a greater loss of both sodium and water because they block sodium reabsorption in the ascending limb of Henle's loop, where 20% to 30% of filtered sodium is normally reabsorbed. Generally, thiazide diuretics, such as hydrochlorothiazide (HydroDIURIL) or chlorthalidone (Thalitone), are prescribed for mild to moderate hypervolemia and loop diuretics for severe hypervolemia.

A client is experiencing edema in the tissue. What type of intravenous fluid would the nurse expect to be prescribed?

hypertonic solution Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 261 A hypertonic solution is used to pull water back in to circulation, as it has more particles than the body's water. If hypertonics are given too rapidly or in large quantities, they may cause an extracellular volume excess and precipitate circulatory overload and dehydration. As a result, these solutions must be given cautiously and usually only when the serum osmolality has decreased to dangerously low levels. Hypertonic solutions exert an osmotic pressure greater than that of the extracellular fluid. The hospitalized client requires treatment for the tissue edema. An isotonic solution is the same concentration as the body's water and is used as an intravenous volume expander. A hypotonic solution has fewer particles than the body's water, thus shifting water from the vascular space to the tissue.

A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypertension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance?

hypokalemia Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 268 Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.

A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should:

instruct the client to breathe into a paper bag.

A client with a history of anxiety experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should:

instruct the client to breathe into a paper bag.

A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the

malignancy is causing the electrolyte imbalance. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 276 The client's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium concentration >10.2 mg/dL (>2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia through a variety of mechanisms. The client's calcium level is elevated; there is no indication that the client's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.

A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance?

metabolic alkalosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 285 Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The client's regular use of baking soda (sodium bicarbonate) may create a risk for this condition. Metabolic acidosis refers to decreased plasma pH because of increased organic acids (acids other than carbonic acid) or decreased bicarbonate. Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary with expired air.

Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

osmosis Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 253 Osmosis is the movement of water through a semipermeable membrane; one that allows some but not all substances in a solution to pass through from a diluted area to a more concentrated area. Filtration promotes the movement of fluid and some dissolved substances through a semipermeable membrane according to pressure differences. Evaporation is the process of converting water into a vapor. Active transport requires the energy source ATP to drive dissolved chemicals from an area of low concentration to an area of higher concentration; the opposite of passive diffusion.

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply.

pH PaCO2 HCO3 Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 283 Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate (HCO3). The two types of acid-base imbalances are acidosis and alkalosis.

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48 Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 285-286 Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 286 In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.

The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis?

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 286-287 Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.

Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting?

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 285 The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis, where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. What client complication associated with respiratory acidosis would the nurse observe?

papilledema Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 286 If respiratory acidosis is severe, intracranial pressure may rise, causing papilledema. Stroke and hyperglycemia are not associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.