Fluid & Electrolytes HURST REVIEW
Signs and symptoms FVD: decreased (4) Dry vitals (3) vasoconstrict (3) labs (3)
decreased CVP, skin turgor, weight, & UO dry mucous membranes Decreased BP, increased respiration & pulse peripheral veins/neck veins vasoconstrict, cool extremities vasoconstrict urine specific gravity, Na, hct increases
Advantage of calcium gluconate?
decreases arrythmias
Common complication with feeding tube clients? Which lab should be checked?
dehydration (check Na)
hypernatremia = too much sodium =
dehydration not enough water
2 causes of hypomagnesemia
diarrhea alcoholism
Hyponatremia = Too much water, not enough _________
dilution sodium
Benefit of hypotonic solution
does not cause HTN
4 Plants that are high in potassium
eggplant fennel potatoes tomatoes
IVF are given slowly to who? (4)
elderly ---> go into fluid overload fast very young kidney disease heart disease
Seeds that are high in magnesium (4)
flax seed pumpkin seeds sesame seeds sunflower seeds
If you've got a sodium problem, you've got a _________ problem
fluid
Hypercalcemia: What prevents kidney stones?
fluids
2 spices & herbs that are high in potassium
ginger root parsley
Precautions to take while giving IV Ca (2)
give slowly make sure the client is on a heart monitor
Hypotonic Solution - where does it go?
goes into the vascular space and then shifts out into the cells to replace cellular fluid "Go out of the vessel"
Trans =
going all the way through
Fish high in magnesium (1)
halibut
Why does pulse increase?
heart is trying to pump what little fluid is left around
The sodium level in your blood is totally dependent on what?
how much water you have in your blood
Causes of hypercalcemia (3)
hyperparathyroidism (too much PTH) immobilization Thiazides
Which IV solution for a client with hyponatremia and neuro symptoms?
hypertonic
2 Complications of giving insulin?
hypoglycemia hypokalemia
Three things that cause hypocalcemia due to not enough PTH
hypoparathyroidism radical neck thyroidectomy
Why/when dialysis?
if the kidneys are not working
Why are extremities cool?
in an effort to shunt blood to the vital organs
CVP is measured where?
in the right atrium
IV potassium should be given by _____ IV potassium should never be given by __ ____
infusion pump IV push
Isotonic Solution - where does it go?
into the vascular space and stays there ""Stay where I put it"
Potassium is excreted by ________________________
kidneys
FVD: Why does BP decrease?
less volume, less pressure
Potassium problems =
life threatening arrhythmias
Ascites leads to (3)
liver problems huge abdomen full of water trouble breathing from diaphragm moving up
Why Spironolactone?
makes you retain potassium
Function of ADH
makes you retain water
More volume =
more pressure
2 main Signs and symptoms hypokalemia
muscle cramps muscle weakness Life threatening arrythmia
3 signs and symptoms of hyperkalemia
muscle twitching muscle weakness flaccid paralysis
Hypomagnesemia & hypocalcemia =
not enough sedative
Calcitonin prevents which disease
osteoporosis
Hypertonic solution means? 2 examples?
packed with particles 3% or 5% NS
Ca has an inverse relationship with ?
phosphorus Phosphorus UP --> Ca DOWN
hypophysis =
pituitary
Causes of hypermagnesemia (2)
renal failure antacids
Treatment for hypernatremia (2)
restrict Na Dilute client with IV fluids
What happens in SIADH
retains water
Signs and symptoms for hypomagnesemia and hypocalcemia: main (1) + signs (2) neuro (3) resp (3) other (1)
rigid and tight muscles tone + Chvostek's & + Trousseau's increase DTR, hallucinations & seizures Stridor/laryngospasm, swallowing problems arrhythmias
Complication of hypertonic solution
risk for FVE
Magnesium and Calcium act like
sedatives
large amount of urine output can lead to what complication?
shock
sphenoid =
sinus
Potassium has an inverse relationship with ______
sodium
Treatment of hyponatremia: Client needs ______ and doesnt need ______
sodium water
ectomy =
taking something out
Examples of loss of fluids: procedures (3) other (3)
thoracentesis paracentesis surgery/trauma vomiting diarrhea hemorrhage
Diabetes Insipidus can be caused by what? (3)
trauma to the head or pituitary gland sinus sx increase ICP
2 Fish that are high in potassium
tuna halibut
Potassium normal value
3.5 - 5.0
If the kidneys are not working well, potassium will go ____
up
DI characteristics
urine output increases & dilute blood is concentrated urine specific gravity, Na, Hmc increases
What is psychogenic polydipsia
water poisoning from drinking too much water
Disease with too little aldosterone
Addisons disease
3 Main Hormonal Regulation of Fluid Volume
Aldosterone Atrial Natriuretic Peptide (ANP) Anti-diuretic hormone (ADH)
hypermagnesemia treatment (4)
Antidote Dialysis safety precautions Ventilator if RR is below 12
Where is ANP found?
Atria of the heart
4 Medications that decrease serum Ca
Biophosphates (etidronate) Calcitonin Prostaglandin Synthesis Inhibitors Steroids
Examples of hypotonic solution (3)
D2.5W 0.45% Na Cl 0.33% NS
3 main causes of hypernatremia
DI heat stroke hyperventilation
Signs & Symptoms FVE: Veins (2) Fluid causes (3) lung sounds UO vitals (2) increased (2)
Distended neck veins/peripheral veins: vessels are full Peripheral edema/third spacing/vessels can't hold anymore and start to leak wet lung sounds Polyuria: kidneys help to diurese increase pulse & BP increased: weight, CVP
4 causes of hypokalemia
Diuretics NG suction not eating vomiting
4 main causes of hyponatremia
Drinking ONLY water for fluid replacement (vomiting/sweating) psychogenic polydipsia (pt LOVES to drink water) D5W (only sugar and water --> can get too diluted) SIADH (retaining TOO MUCH water)
3 main Signs and symptoms of Hypernatremia
Dry mouth swollen tongue (severe) thirsty neuro changes
hypertonic solution- complications? monitor where and for what (3)? which two solutions should be monitored closely?
FVE monitor in an ICU setting frequent monitoring of: BP, pulse & CVP especially if they are receiving 3% or 5% NS
2 Treatments for hypokalemia
Give potassium: eat more potassium, supplement Spironolactone (holds on to K+)
Heart Failure characteristics
Heart is weak; cardiac output decreases decreased kidney perfusion; urinary output decreases Volume stays in the vascular space
Why does drinking water for fluid replacement decrease sodium?
It only replaces water and dilutes the blood
A client weighing 166 pounds (75 kg) is brought to the emergency room with burns to the front and back of both legs and feet. Using the American Burn Association formula to calculate the amount of fluid needed for the first 24 hours, the nurse should set the infusion rate at what for the first eight hours? (Round to nearest whole number). Incorrect The correct Answer is: 338
The American Burn Association formula is 2 - 4mL x weight in kilograms x total surface area burned. Based on the Rule of Nines for adults, a leg is 9% on the front and 9% on the back, which includes the feet. So both legs equal 36% (9% times 4) total surface area burned. The standard multiplier for thermal burns is considered to be 2 mL. Therefore: 2mL x 75 kg x 36 = 5,400 mL for 24 hours. Half that amount, or 2700 mL, should be infused in the first eight hours. Dividing that amount by 8 hours, the infusion rate would be 338 mL per hour. If you missed this question go to page 22 and 26 of your student book for review.
3 ECG changes with hypokalemia
U waves PVCs v tach
Diuretics
- Lasix (worry about HYPOKALEMIA) - Aldactone (NOT LOSING K+ , HYPERkalemia)
Examples of isotonic solutions (4)
0.9% Na Cl, LR D5W d51/4 NS
Mg normal value
1.3-2.1
Sodium normal values?
135-145
Examples of hypertonic solution: 4-NS 1 3
3% NS, 5% NS, D51/2 NS, D5 NS D10W, D5LR, TPN, albumin
Diseases with too much aldosterone
Cushings Cons syndrome LIver Dz Heart Dz
Complications of isotonic solutions (3)
FVE HTN hypernatremia (if solution contains Na)
What should be used for fluid replacement instead of water?
Gatorade
Treatment for hypomagnesemia (2)
Give Mg: PO, supplement, IV seizure precautions
If the fluid goes backwards into the lungs, it can lead to: (2)
Heart failure and pulmonary edema
Which two ways does alcohol cause diureses?
It suppresses ADH (causes diurese) its hypertonic so it draws fluid into vascular space (causing diuresis)
Not enough ADH causes (3)
Lose (water) diurese FVD DI (think diuresis/deficit)
Main treatment for hypercalcemia
Move!
Main cause of hypocalcemia
Not enough PTH
Polyuria can progress from ______ to ____ and _____
Oliguria to anuria
How does ANP work?
Opposite of aldosterone causes excretion of sodium and water
With hyperparathyroidism there is too much of which hormone?
PTH
Treatment FVD (3)
Prevent further loses - stop vomit, bleeding Replace volume - PO or IV fluids Safety precautions - high risk for falls, overload
Two ADH Problems
SIADH DI
Fluid Volume Excess/Hypervolemia
Too much fluid in the vascular space
particle induced diuresis (osmotic diuresis)
Too much particles (sugar) in blood
Must have what vitamin in order to use Ca?
Vitamin D
What sign/symptom would indictate to the nurse that a client has had an inhalation injury? Correct! Select All That Apply 1. stridor 2. Swallowing difficulty 3. Singed nasal hair 4. Blisters to upper arms 5. Wheezing
What sign/symptom would indictate to the nurse that a client has had an inhalation injury? Correct! Select All That Apply1. stridor2. Swallowing difficulty3. Singed nasal hair4. Blisters to upper arms5. Wheezing Rationale 1., 2., 3., & 5. Correct: Substernal/intercostal retraction and stridor are bad signs. Remember you will see difficulty swallowing, singed nasal and facial hair, and wheezing. 4. Incorrect: Blisters found on the oral/pharyngeal mucosa is more likely to indicate a smoke or inhalation injury. If you missed this question, go to page 25 of your student book to review this content.
third spacing definition give 2 examples
When fluid is in the tissues instead of the vascular space burns/ascites
How does hyperventilation cause hypernatremia?
You lose water when you exhale
7 Fruits that are high in potassium
apricots avocado bananna cantaloupe kiwi oranges strawberries
Antidote for hypermagnesemia? how to administer it? Max does?
calcium gluconate IVP very slowly max rate 1.5-2 mL/min
Other types of veggies that are high in magnesium (5)
celery cucumber green bean peppermint summer squash,
Complications of hypotonic solution (3)
cellular edema which can lead to FVD and decreased BP
Uses of hypertonic solution (1) (1) (3)
client who has: hyponatremia shifted large amounts of volume to a 3rd space severe ascites, burns or edema
Indications for hypotonic solution (5)
clients with: HTN, renal or cardiac disease, hypernatremia and for cellular dehydration
Key words to think potential ADH problems (5)
craniotomy head injury, sinus surgery, transsphenoidal hypophysectomy any condition that leads to increased ICP
An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? Correct! Choose One 1. Guillian Barre 2. Severe dehydration 3. Advanced influenza 4. Carbon monoxide poisoning
An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? Correct! Choose One1. Guillian Barre2. Severe dehydration3. Advanced influenza4. Carbon monoxide poisoning Rationale 4. CORRECT. Carbon monoxide is a colorless, odorless, tasteless gas which permeates the blood stream, displacing the oxygen in hemoglobin. Symptoms are often confused with other illnesses, such as the flu. Assuming exposure is not fatal, the client may also experience extreme weakness, dizziness and blurred vision with confusion. Additionally, the carbon monoxide will cause lips and skin to become red in color. Without treatment, the client will die. 1. INCORRECT. Guillian-Barre is a muscle disorder occurring when the immune system attacks peripheral nerves, destroying the surrounding myelin sheath. The damage can develop over hours or days, but will take months to resolve. The client experiences severe weakness, drooping of the eye muscles and pain or tingling in hands and feet. The client also develops paresthesia and paralysis, which was not reported as symptoms in the scenario. Of major concern would be paralysis of the respiratory muscles. 2. INCORRECT. Although the client reported nausea and vomiting, there are no assessment findings in the scenario to corroborate severe dehydration. 3. INCORRECT. The client has reported flu-like symptoms, such as dizziness, nausea and vomiting along with headache. However, additional reported symptoms like blurred vision suggest a different problem. If you missed this question, go to page 24 of your student book for a review.
TX of Hypercalcemia
- get people moving (Ca back to bone) - Fluids (flush out Ca) - phospho soda and fleet enema (has Phosphorus) - Steroids ---------------> LOwer serum Ca - diet : add phosphorus (egg yolk, anything in protein has Phosphorus) - safety precautions - Vit D (to use Ca) - Calcitonin --->Lowers Serum Ca by driving it into the bone .
A client is admitted to the cardiac floor in heart failure. The lung sounds reveal crackles bilaterally, and the BP is 160/98. The client has been on diuretics at home and the potassium level is 3.3 mEq/L (3.3 mmol/L). Which diuretic would the nurse anticipate being prescribed for this client to minimize potassium loss? Choose One 1. Spironolactone 2. Furosemide 3. Bumetanide 4. Hydrochlorothiazide
1. Correct: The client's potassium level is low. Spironolactone is a potassium sparing diuretic which would cause the potassium to be retained. 2. Incorrect: Furosemide is a potassium depleting diuretic which would further deplete the potassium level. 3. Incorrect: Bumetanide is a potassium depleting diuretic which would further deplete the potassium level. 4. Incorrect: Hydrochlorothiazide also leads to potassium loss, which would further deplete the potassium level. Go to page 3 of your student book if you missed this question.
While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? Incorrect Choose One 1. Leave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.
Rationale 3. Correct: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection. 1. Incorrect: This is not appropriate because bacteria is in the scabbing area and ointment would trap it, enhance reproduction of the germs, and increase infection. 2. Incorrect: There is no need to notify primary healthcare provider at this time. This is not the best option for the nurse to fix the problem. 4. Incorrect: We don't put lotion in the wound because this would cause infection of the wound. If you missed this question, go to page 24 of your student book for a review. Review Next Question
What triggers PTH to secrete? What is the function of PTH? What is the final result of PTH
When your serum calcium gets low, PTH kicks in and pulls Ca from the bone and puts it in the blood; therefore, the serum calcium increases
If you want to get Mg and Ca questions right think ________
muscles first
How does bed rest benefit FVE?
when supine --> kidneys perfused more (*UO* goes UP) it induces diurese by the *release of ANP* and *decrease the production of ADH*
Hypertonic solution - What type of solution is it? where does the fluid go?
"volume expander" will draw fluid into the vascular space from the cells "Enter the vessel"
4 treatments of hyperkalemia
- dialysis - calcium gluconate (decrease arrhythmia) - glucose and insulin - sodium polystyrene sulfonate (*k*ayexalate) --------> exchanges Na for K in GI tract --------> Na & K has inverse relationship --------> driving the Na UP in effort to bring K+ down --------> risk for dehydration because of HIGH Na ---> Pushing fluids
Treatment FVE: diet (2) interventions (2) med activity - precaution
- low sodium diet/restrict fluids - I&O and *daily weight* (same time, same clothes, same weight, have pt void first) - Diuretics - bed rest - Physical assessment - Give IVF slow
A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client? 1.Fluid volume excess 2. Cellular edema 3. Severe hypotension 4. Decreasing CVP
1. Correct: Albumin is a hypertonic solution. This type of solution will draw fluid from the cell into the vascular space. This builds up the volume in the vascular space. Therefore, the nurse must watch for fluid volume excess. Hypertonic solutions are used in clients who have 3rd spacing, severe edema, or ascites. 2. Incorrect: Since hypertonic solutions, such as albumin, pull fluid from the cell into the vascular space, we would worry about cellular dehydration and shrinkage, not cellular edema. 3. Incorrect: As the fluid is pulled from the cells into the vascular space, you would expect to see an increase in the BP as the volume in the vascular space increases. You know... more volume, more pressure! We would be watching for hypertension, not hypotension. 4. Incorrect: Think about what we said about the BP when considering the CVP. Since the volume in the vascular space increases with hypertonic solutions, you would also expect the CVP to increase as well. We have to watch closely to make sure that we do not start seeing signs that we are overloading the heart when administering hypertonic solutions. So we will watch this client carefully for an increasing CVP. Go to page 7 of your student book if you missed this question.
A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate? Correct! Select All That Apply 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Place on a spine board. 4. Connect to cardiac monitor. 5. Perform the rule of nines. 6. Apply cervical collar to neck.
1., 2., 3., 4., & 6. Correct: You need to understand that high-voltage current of electricity damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, so we worry about organ failure. Electrical burns have two wounds: an entrance burn wound that is generally small and an exit burn wound that is much larger. The electricity goes throughout the body causing damage, and then exits the body. So look for 2 burn wounds. Remember, vessels, nerves, and organs can be damaged. The nurse needs to monitor vital signs frequently, especially those assessing the respiratory and cardiac systems, since we worry about organ damage. Electricity can damage the heart muscle, so the client is at risk for dysrhythmias within 24 hours following an electrical burn. Put the client on continuous cardiac monitoring during this time. Why place the client on a spine board and put a c-collar on? Contact with electricity can cause muscle contractions strong enough to fracture bones, or vertebrae. The force of the electricity can actually throw the victim forcefully. 5. Incorrect: This statement is false. The rule of nines is not used for electrical burns, but for thermal burns. Most of the damage from electrical burns is internal and cannot be determined by using the rule of nines. If you did not get this question correct, go to page 34 of your student book to review this content.
A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? Incorrect Select All That Apply 1. PO Calcium 2. Rapid IV Push Calcium 3. Vitamin D 4. Sevelamer hydrochloride 5. Phosphate supplements Rationale
1., 3., & 4. Correct: Since this client has hypocalcemia, PO Calcium replacement would be an appropriate treatment. Now, let's look at the others that are not as obvious. Vitamin D helps to improve calcium absorption, which will help increase the calcium levels. So, what is sevelamer hydrochloride and how will this help hypocalcemia? Well, it is a phosphate binder. And remember that we said if you bind the phosphorus, the phosphorus levels go down. And since phosphorus and calcium have inverse relationships, as the phosphorus levels go down, the calcium levels will go up! 2. Incorrect: IV Calcium should be administered slowly or by slow infusion and the client should always be on a heart monitor. If you give calcium too rapidly by IV, the client may have vasodilation, hypotension bradycardia, cardiac arrhythmias, syncope, and cardiac arrest. Don't forget to be watching for the widening of the QRS complex when administering IV calcium! 5. Incorrect: Phosphate supplements would cause the calcium to be even lower in this client. Remember, phosphorus and calcium have an inverse relationship. We would give phosphate binders, not supplements. Go to page 9 of your student book if you missed this question.
A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mEq/L (149 mmol/L). What action by the nurse would be most appropriate at this time? 1. Administer 3% NS at 150 mL/hr 2. Perform neurological assessment 3. Increase oral intake of sodium 4. Decrease fluid intake
2. Correct: Did you recognize that the sodium level of 149 is too high? The normal sodium level is 135-145 mEq/L (135-145 mmol/L). Think about the testing strategy that we mentioned to you. Look for neuro changes when the sodium level is not within normal limits. The brain does not like it when the sodium level is messed up. So, performing a neurological assessment on this client would be important. 1. Incorrect: What type of fluid is 3% NS? It's a hypertonic solution that contains a lot of sodium! That would be a killer answer here because this client's sodium level is already too high! 3. Incorrect: The sodium level is too high. The nurse would have the client to decrease, not increase, the oral intake of sodium. 4. Incorrect. With hypernatremia, there is too much sodium and not enough fluid. Therefore, you would want this client to increase, not decrease, the fluid intake to dilute the sodium level in the blood. Go to page 10 of your student book if you missed this question.
A client is admitted following a severe burn. What changes related to fluid status would the nurse anticipate? Incorrect Select All That Apply 1. Fluid volume excess 2. Hypovolemia 3. Third spacing 4. Increased urine output 5. Low CVP 6. Increased urine specific gravity
2., 3., 5., & 6 Correct: Causes of fluid volume deficit (hypovolemia) include loss of fluid from anywhere as well as third spacing of fluid that occurs with such things as burns. Burns can result in fluid loss from the burn area as well as the third spacing, which increases the risk for hypovolemia and shock. As the fluid volume decreases, the BP and CVP both decrease. Remember, less volume, less pressure. Also, when the fluid volume becomes depleted, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. You will see the urine specific gravity increase because the small amount of urine being produced will be very concentrated. 1. Incorrect: The client with a severe burn will lose fluids from the burn area and will also third space fluid to a place that does them no good. Therefore, they will go into a fluid volume deficit, not a fluid volume excess. 4. Incorrect: When the fluid volume becomes depleted, such as what occurs with burns, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. Go to pages 4-5 of your student book if you missed this question.
The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? Select All That Apply 1. Liver function 2. Respiratory rate 3. Calcium levels 4. Deep Tendon Reflexes (DTRs) 5. Urinary output
2., 4., & 5 Correct: As you learned, magnesium acts like a sedative. Since we know that magnesium can cause respiratory depression, the nurse should always have a baseline respiratory assessment prior to initiating an infusion of magnesium. Muscle tone and DTRs can also become depressed, so a baseline assessment of DTRs would be very important. How is magnesium excreted? That's right! Through the kidneys. The nurse should always assess kidney function and urinary output prior to and during IV magnesium administration because of the risk of magnesium toxicity if it is being retained. 1. Incorrect: Magnesium administration does not impair liver function, so although the alcoholic client may have altered liver function, this is not an assessment that the nurse would be most concerned about related to magnesium administration. In fact, hypomagnesemia is a common problem in alcoholics which may require increasing foods high in magnesium or magnesium supplementation by PO or IV routes. 3. Incorrect: Magnesium levels are not influenced by calcium levels, so this is not an assessment that would be a priority for the nurse at this time. Go to page 9 of your student book if you missed this question.
What information on burn prevention strategies should the nurse include when providing an education program at a community center? Correct! Select All That 1. Have chimney professionally inspected every 5 years. 2. Clean the lint trap on the clothes dryer after each use. 3. Keep anything that can burn at least 1 foot (0.30 meters) away from space heaters. 4. Do not hold a child while holding a hot drink. 5. Home hot water heater should be set at a maximum of 120°F (48.8°C).
2., 4., & 5. Correct: Lint that accumulates in the lint trap of a dryer can cause a fire, so the lint trap should be cleaned after each use. A hot beverage can easily spill on a child by accident when trying to handle both the beverage and child at the same time. Home hot water heater should be set at a maximum of 120°F (48.8°C), especially when small children, the elderly, or diabetics are in the home. 1. Incorrect: A chimney should be professionally inspected every year prior to use. It should also be cleaned if necessary. 3. Incorrect: Space heaters need space at least three feet (0.91 meters) away from anything that can burn. If you missed this question, review your notes on page 20 of your student book.
An elderly client with partial and full-thickness burns has begun receiving fluids at 600 ml/hour, as determined by the Parkland (Consensus) Formula. Based on the assessment data for the first four hours, what should the nurse report to the primary healthcare provider? Exhibit Correct! Choose One1. The cardiovascular system is becoming seriously overloaded2. The speed of the IV should be reduced since CVP is now normal3. The changes in vital signs indicate an expected response to fluids4. The client is deteriorating because of age and extent of the burns Rationale 3. CORRECT. The purpose of infusing large amounts of fluid into burn victims during the first 24 hours is to help maintain perfusion until the body's physiology returns to normal functioning. The serial vital signs indicate the cardiovascular system is stabilizing, as evidenced by pulse decreasing to the normal range while blood pressure increases. Though respirations are still slightly elevated, the client would likely be experiencing pain. Most importantly, the CVP (central venous pressure) has increased to the normal range, indicating the fluid replacement is adequate at this time. 1. INCORRECT. There is no evidence indicating possible cardiac overload. The client's vital signs are stabilizing and the central venous pressure (CVP) has returned to normal limits. 2. INCORRECT. When fluid replacement is calculated for burn clients, the amount is based on client weight in kilograms and total surface area burned. Those parameters do not change during the initial treatment. Therefore the amount of fluid needed during the first 24 hours remains unchanged until after that time frame, even if vital signs improve. 4. INCORRECT. The hourly data does not reflect deterioration. Vital signs are slowly returning to within normal range and there is no mention in the scenario about the extent of burns. If you missed this question you need to review fluid volume deficit, pages 4-5, and pages 25-26 of your student book.
3. CORRECT. The purpose of infusing large amounts of fluid into burn victims during the first 24 hours is to help maintain perfusion until the body's physiology returns to normal functioning. The serial vital signs indicate the cardiovascular system is stabilizing, as evidenced by pulse decreasing to the normal range while blood pressure increases. Though respirations are still slightly elevated, the client would likely be experiencing pain. Most importantly, the CVP (central venous pressure) has increased to the normal range, indicating the fluid replacement is adequate at this time. 1. INCORRECT. There is no evidence indicating possible cardiac overload. The client's vital signs are stabilizing and the central venous pressure (CVP) has returned to normal limits. 2. INCORRECT. When fluid replacement is calculated for burn clients, the amount is based on client weight in kilograms and total surface area burned. Those parameters do not change during the initial treatment. Therefore the amount of fluid needed during the first 24 hours remains unchanged until after that time frame, even if vital signs improve. 4. INCORRECT. The hourly data does not reflect deterioration. Vital signs are slowly returning to within normal range and there is no mention in the scenario about the extent of burns. If you missed this question you need to review fluid volume deficit, pages 4-5, and pages 25-26 of your student book.
A client was admitted with reports of prolonged diarrhea. The client's admission potassium level was 3.3 mEq/L (3.3 mmol/L) and is receiving an IV of D5 ½ NS with 20 mEq KCL at 125 mL/hr. The UAP reports an 8 hour urinary output of 200 mL. The previous 8 hour urinary output was 250 ml. What should be the nurse's priority action? 1. Encourage the client to increase PO fluid intake. 2. Administer a supplemental PO dose of potassium. 3. Stop the IV potassium infusion. 4. Administer polystyrene sulfonate PO
3. Correct: First, you need to recall that potassium is excreted by the kidneys. If the kidneys are not working well, the serum potassium will go up! You always monitor the urinary output before and during IV potassium administration. Since the urine output has decreased below 30 mL/hr, we know that the urinary output is not adequate. Therefore, the client could start retaining too much potassium. The priority action would be to stop the infusion and then follow this action by notifying the healthcare provider. 1. Incorrect: You may have picked up on the decreased output and thought that you could increase PO fluid intake to increase output. However, the priority action would be to first stop the potassium infusion until the urinary output is adequate. This is a safety issue. 2. Incorrect: We do not want to administer any more potassium to this client. The urine output is not adequate and the client could be retaining too much potassium. 4. Incorrect: Polystyrene sulfonate (Kayexalate®) is used as a treatment for clients with known hyperkalemia. We are trying to prevent this client from becoming hyperkalemic by stopping the IV potassium infusion as the urine output has decreased. Go to pages 11-12 of your student book if you missed this question.
What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim? Correct! Choose One 1. Remove jewelry. 2. Wrap in a clean blanket. 3. Cover burns with clean, dry cloth. 4. Briefly soak burned area in cool water.
4. Correct: Although all options are correct, the priority is to stop the burning process. Just putting out the flames is not enough to stop the burning process. You need to apply cool water briefly (no more than 10 minutes) to soak the burn area. Any longer can cause extensive heat loss. 1. Incorrect: Removing jewelry is important but stop the burning process first. Swelling occurs with burns, so jewlrey must be removed or you will not get it off. This can result in constriction of the extemity. Additionally, metal burns. 2. Incorrect: Wrapping the client in a clean or preferably a sterile blanket will help to hold in body heat. Remember, they have lost skin, the number one way to hold in body heat. 3. Incorrect: Applying a clean, dry cloth to the burn area will help prevent infection, but the priority is to stop the burning process. If you missed this question, go to page 23 of your student book for review.
A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? 1. Low serum hematocrit 2. High serum glucose 3. High urine protein 4. Low urine specific gravity
4. Correct: Diabetes insipidus is a condition that results from decreased ADH production. Therefore, the client will be diuresing large volumes of water which leads to a fluid volume deficit. We worry about shock in these clients. Keep in mind that concentrated makes #s go up and dilute makes #s go down in reference to specific gravity, sodium, and hematocrit. Here, the urine is very dilute which means the urine specific gravity will be low. 1. Incorrect: As the client loses volume through the kidneys, the blood (serum) will become very concentrated. Therefore, you would expect the hematocrit to be high, not low. 2. Incorrect: Don't let the name diabetes insipidus trick you into thinking it affects the glucose level. It is an ADH problem, not a glucose problem. We are worried about fluid volume deficit here. 3. Incorrect: You do not expect to see protein in the urine in DI. In fact, protein is not seen in the urine unless there is a kidney problem. This is an ADH problem, not a kidney problem. You are worried about a large amount of water loss with this client. If you missed this question, review the content again on page 2 of your student book.
Ca normal value
9.0 - 10.5
Intervention before/during IV potassium
Assess urinary output
Intervention is required with which client? Client with a history of grand-mal seizures or a client that is 8 hours post heart cath?
Client that is 8 hours post heart cath due to high risk of hemorrhage
Three things with a lot of sodium
Effervescent soluble medications (Alka-seltzer) Canned/processed foods IVF with sodium
Adverse effect of potassium supplement? How to prevent adverse effect?
GI upset give with food
Contradictions for isotonic solutions (3)
HTN cardiac disease kidney disease
3 main signs and symptoms of hyponatremia
Headache seizures coma
Causes of FVE: (3)
Heart Failure Renal Failure Sodium
Why insulin?
Insulin carries glucose and potassium into the cell ---> anytime give IV insulin worry about : 1) HYPOglycemia 2) HYPOkalemia
Why Glucose
Insulin is carrying glucose out of blood vessels and into the cells --> BSG drops --> give glucose to balance it out / prevent hypoglycemia
Why does alcohol cause hypomagnesemia
It causes diurese
Reasons for decreased urine output (2)
Kidneys either aren't being perfused or they are trying to hold on to fluid to compensate
What is the basic solution when administering blood?
NS
ADH is found in the ?
Pituitary
A client arrives at the emergency department after sustaining full thickness burns. What does the nurse estimate the total body surface area (TBSA) burned to be when using the rule of nines?
Posterior trunk = 18 Posterior arm = 4.5 TBSA burned = 22.5% If you missed this question, go to page 22 of your student book for review. Review Next Question
A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests? Incorrect Select All That Apply 1. Hematocrit 2. Albumin 3. Potassium 4. Creatinine 5. Magnesium
Rationale 1, 3, & 4. CORRECT. The physiology of the body changes significantly following a major burn. Hematocrit increases as the fluid from the vascular spaces leaks into the interstitial tissues. Because of lysis of cells, potassium is released into the circulation, leading to hyperkalemia. The kidneys are impacted by the decreased cardiac output as well as the myoglobin released by the lysed cells. This causes creatinine to become elevated. 2. INCORRECT. Albumin, a body protein, is lost through the damaged skin areas and secondary to increased capillary permeability. 5. INCORRECT. Magnesium is a major electrolyte necessary for both muscle and nerve function. Since the body does not produce magnesium naturally, humans need a well-balanced diet which includes a variety of vegetables and seeds. Levels of magnesium are not affected during the initial period after a burn. If you mised this question you need to review FVD on pages 4-5, and burns on pages 26-27. Review Next Question
A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would best indicate understanding of the teaching? 1. "The increased level of ADH will cause my potassium level to be too high." 2. "I will be retaining sodium and water due to the increased amount of aldosterone." 3. "I will be losing lots of fluid due to the hormonal imbalance I have." 4. "I will feel jittery and nervous due to the elevated thyroxine levels."
Rationale 2. Correct: Cushing's is a disease that results in increased secretion of aldosterone. Having too much aldosterone causes the client to be at risk for fluid volume excess (FVE) due to the increased retention of both sodium and water. 1. Incorrect: Cushing's is a problem associated with an increased production of aldosterone, not ADH. The client will be retaining both sodium and water. 3. Incorrect: The client would not be losing excess fluid as is seen in clients with Diabetes Insipidus (DI), an ADH problem. The client will be retaining both sodium and water due to the increased aldosterone and would be at risk for fluid volume excess. 4. Incorrect: Increased thyroxine levels is related to hyperthyroidism, not Cushing's disease. This client has a problem with too much aldosterone and a resulting FVE. If you missed this question, go back and study page 1 in your student book.
The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? Select All That Apply 1. Broiled, fresh fish 2. Effervescent soluble medications 3. Seasoning with lemon pepper 4. Chicken noodle soup 5. Deli-ham sandwiches
Rationale 2., 4., & 5. Correct: Think about fluid volume excess and heart failure. Things such as effervescent soluble medications and canned/processed foods should be avoided because they all contain a lot of sodium which increases fluid retention. Therefore, the chicken noodle soup and the cold cut deli-ham sandwiches should be avoided. 1. Incorrect: Fresh fish is a good, healthy selection that is low in sodium, which is what this client needs. Make sure to avoid smoked or cured fish/meats because these would have a higher sodium content. 3. Incorrect: Salt, as a seasoning, should be avoided because this would increase the fluid retention problem. However, a good alternative to salt for seasoning foods is to use lemon, lemon juice, and pepper. These are lower in sodium than salt. If you missed this question, go to page 1 of your student book to review.
Fluid Volume Deficit: Hypovolemia Big time deficit =
Shock
A client receiving magnesium sulfate has a drop in output: What would be the priority nursing intervention? 1. Call the primary healthcare provider 2. Decrease the infusion 3. Stop the infusion 4. Reassess in 15 minutes
Stop the infusion!
SIADH characteristics
Urine output; decreases, concentrated blood is dilute urine specific gravity, Na, and Hmt decreases
While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? Incorrect Choose One1. Leave the scabbing area alone and apply extra ointment.2. Notify the primary healthcare provider.3. Gently remove the debris and re-dress the wound.4. Apply skin softening lotion for 3 hours and then re-dress. Rationale 3. Correct: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection. 1. Incorrect: This is not appropriate because bacteria is in the scabbing area and ointment would trap it, enhance reproduction of the germs, and increase infection. 2. Incorrect: There is no need to notify primary healthcare provider at this time. This is not the best option for the nurse to fix the problem. 4. Incorrect: We don't put lotion in the wound because this would cause infection of the wound. If you missed this question, go to page 24 of your student book for a review. Review Next Question
While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? Incorrect Choose One1. Leave the scabbing area alone and apply extra ointment.2. Notify the primary healthcare provider.3. Gently remove the debris and re-dress the wound.4. Apply skin softening lotion for 3 hours and then re-dress. Rationale 3. Correct: What likes to live in the scabs and dried blood? Bacteria. That is why it is important to remove the debris to prevent infection. 1. Incorrect: This is not appropriate because bacteria is in the scabbing area and ointment would trap it, enhance reproduction of the germs, and increase infection. 2. Incorrect: There is no need to notify primary healthcare provider at this time. This is not the best option for the nurse to fix the problem. 4. Incorrect: We don't put lotion in the wound because this would cause infection of the wound. If you missed this question, go to page 24 of your student book for a review. Review Next Question
Where is aldosterone found
adrenal glands
Other vegetables that are high in potassium (4)
bell pepper cauliflower cucumber lima beans
Normal action of aldosterone
blood volume gets low (vomiting, hemorrhage) } aldosterone secretion increases } retain Na & water } blood volume goes up
ECG changes with hyperkalemia: (3) T waves? PR interval? P waves? QRS?
bradycardia, conduction blocks, V fib tall and peaked prolonged flat or absent widened
Two main Signs and symptoms hypercalcemia
brittle bones kidney stones
Green Veggies high in potassium (6)
broccoli brussel sprouts cabbage kale mustard green spinach
Green leafy Veggies high in Mg (5)
broccoli kale mustard greens spinach turnip greens
Uses of isotonic solutions: When the client has lost fluids through (4)
burns, sweating, trauma and vomiting
Treatment for hypocalcemia (4 meds)
calcium acetate IV Ca (can lower HR, widen QRS complex, pt should always be on Heart monitor) Phosphate binders: sevelamer hydrochloride (meds are binding w/PHosphorus --> serum Ca went down) Vitamin D ( so you can use the ca you have)
Interventions for hypernatremia (3)
daily weights I & O lab work
Common symptoms of hypermagnesemia and hypercalcemia: (think too much sedative) Decreased (4) (1) (2)
decrease DTR decreased LOC decrease pulse decrease respirations arrhythmias weak and flaccid muscle tone
What to check before IV administration of Mg
kidney function (because kidneys are the only way to excreter Mg --> bad kidney func = Hypermagnesemia)
If a client receiving IV Mg sulfate has a hourly UO of 180. next hour UP is 140. what is happening `
kidney function decreasing (REMEMBER : Mg can only be excreted via . retaining Mg. What do you do? - stop the infusion
2 Main causes of hyperkalemia
kidney problems spironolactone
Characteristics of Addisons
less aldosterone decreased sodium/water FVD
Why does CVP decrease?
less volume less pressure
3 Causes of FVD
loss of fluids from anywhere third spacing diseases with polyuria
What should be added to the diet with hypercalcemia?
protein=phosphorus
What do you do if your client reports flushing, and sweating when you start the IV Mg?
stop the infusion signs and
Think what for sodium problems?
think neuro changes
Magnesium makes you _______________ 3 main hypermagnesemia signs and symptoms
vasodialate decrease BP flushing warmth
Another name for anti-diuretic hormone (ADH) that may be used as an ADH replacement in DI?
vasopressin desmopressin acetate
How to administer hypertonic solution?
very slowly
Sodium follows _______?
water
Treatment for SIADH
water restriction 3% Na Cl
Too much ADH causes (3)
water retention FVE SIADH (too many letters, too much water)
How does immobilization cause hypercalcemia?
you have to bear weight to keep calcium in the bones If you do not bear weight, calcium will leave the bones
