Chapter 40 fluid, electrolyte, acid base balance

Which is a common anion? (negative charge)

Chloride

The process of filtration begins at the:

The process of filtration begins at the glomerulus.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed.

What is the function of Bicarbonate?

body's primary buffer system

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

calcium and phosphorus

The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching?

cardiac function Potassium is essential for normal cardiac function.

What is the function of potassium?

chief regulator of cellular enzyme activity and water content

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

every 72 hours

What should you assess for in a patient suspected to have hypokalemia (low potassium)?

fatigue, anorexia, nausea, vomiting, muscle weakness, decreased bowel motility, cardiac arrhythmias.

8.6-10.2 mg/dL

normal calcium levels

The primary extracellular electrolytes are:

sodium, chloride, bicarbonate

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

Hyperphosphatemia. Calcium and phosphorus have a reciprocal relationship—if the calcium level is low, the phosphorus level would be high.

tongue turgor

In a normal person, the tongue has one longitudinal furrow; with sodium excess the tongue appears red and swollen.

In which fluid compartment is most of the body's fluid is located?

Intracellular is the fluid within cells, constituting about 70% of the total body water

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply.

Persons with type AB blood are often called universal recipients, a fact that is rooted in their lack of agglutinins for either A or B antigens.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

Phlebitis

What should you assess for in a patient with Hypocalcemia (low calcium)?

Trousseau and Chvostek signs. Numbness and tingling of fingers and toes. Mental changes, seizures, spasm of laryngeal muscles. ECG changes, cramps in muscle extremities.

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

daily weights

A dialysis unit nurse caring for a client with acute kidney injury will expect the client to exhibit which fluid and electrolyte imbalances?

fluid volume excess and acidosis

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia. The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the health care provider of the client's:

low calcium. Normal total serum calcium levels range between 8.9 and 10.1 mg/dL.

25-29 mEq/L

normal serum bicarbonate level

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

1+ The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents. "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented?

3+ pitting edema

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

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

What should you assess for in a patient with Hypermagnesemia ( High magnesia) ?

Flushing and sense of skin warmth. Hypotension, depressed respirations, drowsiness, hypoactive reflexes.

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?

Infants

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

Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body.

What should you assess for in a patient with hyperphosphatemia?

Short term consequences: Tetany, such as tingling of the fingertips and around the mouth, numbness, and muscle spasms. Long term consequence: Precipitation of calcium phosphate in kidneys, joints, arteries, skin, or cornea.

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?

muscle cramping and tetany

135-145 mEq/L

normal sodium levels

What is the function of calcium?

1. Forms and maintains bones and teeth 2. Coagulates blood (vitamin D helps absorb calcium) 3.Muscle contraction

A health care provider has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

60 drops/mL

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV.

What is the function of sodium?

controls and regulates volume of body fluids

pituitary gland

stores and releases the antidiuretic hormone.

What are normal calcium levels?

8.5-10.5 mg/dL

What should you asses in a patient with hyponatremia (low sodium) ?

Anorexia, Nausea, Lethargy, confusion, Muscle cramps, seizures, coma

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document?

Grade 2 phlebitis. Grade 3 presents the same as grade 2 but also with a streak formation and palpable venous cord.

A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed?

Hypertonic

What should you assess for in a patient with Hypomagnesemia (Low magnesium)?

Increased reflexes, seizures, coarse tremors, cardiac manifestations, tachyarrhythmias.

What should you asses in a patient with hypernatremia (high sodium) ?

Thirst, elevated body temp, dry and swollen tongue, sticky mucous, Hallucinations, lethargy, Irritable and hyperactive, Focal or grand mal seizures, coma.

The nurse writes a a problem-based care plan, citing the client's excess fluid volume. What risk factor does the nurse expect to assess in this client?

acute kidney injury

What is the function of magnesium?

metabolism of carbs and proteins, vital actions involving enzymes

97-107 mEq/L

normal chloride levels

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as

total parenteral nutrition.

The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

Fluid intake and fluid output should be approximately the same in order to maintain fluid balance.

what is the function of phosphate?

involved in important chemical reactions in the body, cell division, and hereditary traits

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would depend on as the most reliable indicator of a patient's fluid balance status?

Measuring weight daily.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?

The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute.

A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted?

10- to 15-degree angle

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient?

1. "Try to drink at least six to eight glasses of water each day." 2."Limit sugar, salt, and alcohol in your diet." 3. "Report side effects of medications you are taking, especially diarrhea. 4. "Weigh yourself daily and report any changes in your weight."

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition?

1. 0.33% NaCl (1/3-strength normal saline) 2. 0.45% NaCl (1/2-strength normal saline)

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply.

1.The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. 2.A symptom of fluid overload is distended neck veins. 3.Fluid overload is more likely in very young children. 4.The infusion rate must be carefully monitored during the administration of blood.

A client has been diagnosed with stage II breast cancer and will require 8 weeks of chemotherapy. Which intravenous access would the nurse anticipate?

A Groshong catheter is a tunneled catheter that is frequently used for extended therapy. The tunneling helps to secure the catheter, as well as reduce the potential for infection.

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance?

All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas ABGs are used to assess acid-base balance.

What should you assess for in a patient with hypophosphatemia? (low phosphate)?

Cardiomyopathy, acute respiratory failure, seizures, decreased tissue oxygenation, joint stiffness, greater risk for infection.

What places you at risk for Hypomagnesemia?

Chronic alcoholism Intestinal malabsorption Drugs Diarrhea

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

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

What should you assess for in a patient with Hypermagnesemia (high magnesium)?

Flushing and sense of skin warmth. Cardiac abnormalities, hypotension, depressed respirations, drowsiness, hypoactive reflexes.

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.

Intravenous therapy, Electrolyte management, Nutrition management.

Food rich in phosphate

Poultry, milk, bread, ready to eat cereal

The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next?

The assessment findings of a swollen IV site with surrounding tissue swelling and cool to touch indicate infiltration. The correct action for an infiltrated IV is to remove the IV. Decreasing the rate of fluids requires the health care provider's prescription and is not indicated for infiltration.

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?

The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min

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

The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac arrythmias.

What should you assess for in a patient with hyperkalemia (high potassium)?

Vague muscle weakness, cardiac arrhythmias, paresthesia of face, tongue, feet, and hands. Flaccid muscle paralysis, GI disturbances.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to theses symptoms?

a. slow or stop infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. That is why (a) is the correct answer.

The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect?

hypocalcemia

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?

hypovolemia The nurse should recognize that hypovolemia, also known as dehydration, may be responsible.

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?

maintenance of cell size.

1.3-2.3 mEq/L

normal magnesium levels

2.5-4.5 mg/dL

normal phosphorus levels

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

"Watery plasma, or serum, portion of blood."

Risk factors for Hyperphosphatemia.

Renal failure, Chemotherapy, Large intake of milk, Large vitamin D intake, Hyperthyroidism, excessive us of laxatives.

The nurse is preparing to perform venipuncture. Which items will the nurse plan to gather? Select all that apply.

1.clean gloves 2.tourniquet 3.antiseptic swabs 4.transparent dressing 5.adhesive tape

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?

ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the:

Lungs

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

Metabolic alkalosis

What should you assess for in a patient with hypercalcemia (High calcium)?

Muscular weakness, Tiredness, Constipation, Anorexia, Nausea, Decreased memory, Renal stones.

A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?

The nurse looks for a large vein when using a needle with a large gauge to prevent compromising circulation.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?

The priority nursing action is to tighten the roller clamp on the tubing as this action prevents forward movement of air

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

The renal system retains more water.