**fluid electrolyte Balance

A nurse is caring for a 3-year-old client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. His laboratory test results indicate a Hgb of 12.5 g/dL (125 g/L), HCT of 36.8% (0.37), WBC of 2000 mm3 (2 X 109/L), and platelet count of 150,000/μL (150 X 109/L). Based on the child's values, what is the highest priority nursing intervention? Prepare to give the child a transfusion of packed red blood cells. Encourage meticulous handwashing by the client and visitors. Encourage mouth care with a soft toothbrush. Prepare to give the child a transfusion of platelets.

Encourage meticulous handwashing by the client and visitors. Explanation: A WBC of 2000 mm3 (2 X 109/L) is low and increases the child's risk for infection. Meticulous handwashing is a standard/routine precaution and the first line of defense in combating infection. A platelet count of 150,000 ?L (150 X 109/L) is within normal range, so there is no need to transfuse the child with platelets. Mouth care will help decrease the risk of infection. However, handwashing is the priority because it will have the greatest effects on diminishing the risk of infection. A Hgb of 12.5 g/dL (125 g/L) and a HCT of 36.8% (0.37) are within normal range so there is no need to transfuse packed red blood cells.

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? Minimal urine output of 10 mL per hour Minimal intake of 1.5 liters per day Minimal intake of 2 liters per day Minimal urine output of 50 mL per hour

Minimal intake of 1.5 liters per day

The calcium level of the blood is regulated by which mechanism? Adrenal gland Androgens Parathyroid hormone (PTH) Thyroid hormone (TH)

PTH

What percentage of potassium that is excreted daily, leaves the body by way of the kidneys? 60 40 80 20

80

Patients diagnosed with hypervolemia should avoid sweet or dry food because it increases the patient's desire to consume fluid. it can cause dehydration. it can lead to weight gain. it obstructs water elimination.

it increases the patient's desire to consume fluid.

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? Respiratory acidosis Altered blood urea nitrogen (BUN) value Metabolic alkalosis Extracellular fluid volume deficit

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 decreaesd fluid intake. A cause of this loss is hemorrhage.

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? Distended jugular veins Cool and pale skin Dark, concentrated urine Crackles in the lung fields

Dark, concentrated urine

Upon shift report, the nurse learns 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 is the client most likely experiencing? Compensated metabolic alkalosis Compensated metabolic acidosis Compensated respiratory alkalosis Uncompensated respiratory alkalosis

Compensated respiratory alkalosis 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 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 alkalosis Respiratory alkalosis Metabolic acidosis Respiratory acidosis

Metabolic acidosis Explanation: 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.

A patient is being treated in the ICU 24 hours after having a radical neck dissection completed. The patient's serum calcium level is 7.6 mg/dL. Which of the following physical examination findings is consistent with this electrolyte imbalance? Muscle weakness Negative Chvostek's sign Presence of Trousseau's sign Slurred speech

Presence of Trousseau's sign A patient status post radical neck resection is prone to developing hypocalcemia. Hypocalcemia is defined as a serum values lower than 8.6 mg/dL [2.15 mmol/L]. Signs and symptoms of hypocalcemia include: Chvostek's 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's 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.

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance? respiratory alkalosis respiratory acidosis metabolic acidosis metabolic alkalosis

metabolic alkalosis Explanation: Metabolic alkalosis occurs because of the excessive loss of potassium, hydrogen, and chloride in the vomitus. Chloride loss leads to a compensatory increase in the number of bicarbonate ions. The bicarbonate side of the carbonic acid-base bicarbonate increases, and the pH becomes more alkaline. Respiratory alkalosis is caused by conditions such as hyperventilation that result in loss of partial pressure of arterial carbon dioxide (PaCO2). Respiratory acidosis is caused by conditions such as inadequate ventilation that result in excessive retention of PaCO2. Metabolic acidosis results from the loss of large amounts of bicarbonate, such as with severe diarrhea.

A young woman presents with vaginal itching and irritation of recent onset. Her labia are swollen, and she has a frothy yellowish discharge with an unpleasant smell and a pH of 6.8. She has been celibate during the last six months and has been taking antibiotics for a throat infection. Which medication is most likely to clear her symptoms? azithromycin valacyclovir penicillin metronidazole

metronidazole Explanation: The character of the discharge, lack of recent sexual activity, and current antibiotic treatment point to infection with Trichomonas vaginalis, which can exist asymptomatically and flare up only if conditions, such as an imbalance in normal vaginal flora resulting from antibiotic treatment, enable the protozoan to proliferate. Trichomoniasis responds well to treatment with metronidazole.

A nurse teaches a client experiencing heartburn to take 1.5 oz of aluminum hydroxide when symptoms appear. How many milliliters should the client take? Record your answer using a whole number.

45 Explanation: 1 oz = 30 mL. (1 oz/1.5 oz) = (30 mL/x). x = (1.5 X 30) mL. x = 45 mL.

Which of the following electrolyte imbalances occur with adrenal insufficiency? Hyperkalemia Hypernatremia Hypokalemia Hyponatremia

*Hyperkalemia occurs with adrenal insufficiency*. *Hypokalemia occurs with gastrointestinal and renal losses*. *Hyponatremia occurs with increased thirst and antidiuretic hormone* (ADH) release. *Hypernatremia results from increased insensible losses and diabetes insipidus*.

A 77-year-old retired male client visits your general practice office twice monthly to maintain control of his congestive heart failure. He measures his weight daily and phones it to your office for his medical record. In a 24-hour period, how much fluid is this client retaining if his weight increases by 2 lb? 1500 ml 1250 ml 500 ml 1 L

1L

A patient presents to the Emergency Department experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient's pH value to be which of the following? 7.35 7.45 7.30 7.50

7.50 The patient is experiencing respiratory alkalosis. *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. 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.

The nurse observes a client's uric acid level of 9.3 mg/dL. When teaching the client about ways to decrease the uric acid level, which diet would the nurse suggest? A diet high in fruits and vegetables A diet high in calcium A low-purine diet A low-sodium diet

A low-purine diet Explanation: The nurse would suggest a low-purine diet. Foods to avoid are anchovies, animal organs and sardines. The other options do not lower the uric acids levels.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? Pulmonary function Hemoglobin levels Arterial blood gas Hematocrit values

Arterial blood gas Explanation: Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

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? Nitrogen Bicarbonate Carbonic acid Lactate

BICARBONATE 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. Carbonic acid, lactate and nitrogen levels are not shown in an ABG.

A client who is blind is admitted for treatment of a small bowel obstruction and has been vomitting for days. Which nursing diagnosis takes highest priority for this client? Impaired physical mobility Activity intolerance Deficient fluid volume Risk for injury

Deficient fluid volume Explanation: Although the client's disability should be considered in the course of assessment and delivery of health and nursing care, it should not become the overriding focus or exclusive focus of the assessment or the care that the client receives. Because the client has been vomitting for days, he is most likely dehydrated; therefore, deficient fluid volume takes highest priority. A sensory deficit such as blindness puts the client at risk for injury from the environment; however, a ptoential problem doesn't take highest priority.

To confirm an acid-base imbalance, it is necessary to assess which findings from the results of a client's arterial blood gas (ABG) results? Select all that apply. K+ Na+ HCO3 PaCO2 pH Nitrogen

HCO3 PaCO2 pH

Which of the following would be a potential cause of respiratory acidosis? Diarrhea Hypoventilation Vomiting Hyperventilation

HYPOVENTILATION Respiratory acidosis is always due to inadequate excretion of CO, with inadequate ventilation, resulting in elevated plasma CO concentration, which causes increased levels of carbonic acid. In addition to an elevated PaCO, hypoventilation usually causes a decrease in PaO.

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? Hypovolemia contains only low blood volume. In dehydration, only extracellular is depleted. Similar causes are present in both conditions. Both conditions result in abnormal laboratory studies.

In dehydration, only extracellular is depleted. 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 of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. Administer the ordered Furosemide (lasix) 60 mg po. Offer a diet with fruit juices and citrus fruits. Administer the ordered potassium 40 mg IV push. Administer the ordered Kayexalate enema. Monitor intake and output every shift.

Monitor intake and output every shift. Offer a diet with fruit juices and citrus fruits.

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. Administer an ordered decongestant. Offer the client fluids frequently. Administer ordered supplemental oxygen.

Instruct the client to breathe into a paper bag. Explanation: 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.

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings? Hyperchloremia Hypophosphatemia Hypokalemia Hypernatremia

K + 3.0 mEq/L Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Hallucinations or tinnitus Nausea or vomiting Light-headedness or paresthesia Abdominal pain or diarrhea

Light-headedness or paresthesia Explanation: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

A patient who has been treated for uric acid stones is being discharged from the hospital. What type of diet does the nurse discuss with the patient? High-protein diet Low-purine diet Low-phosphorus diet Low-calcium diet

Low-purine diet Explanation: For uric acid stones, the patient is placed on a low-purine diet to reduce the excretion of uric acid in the urine. Foods high in purine (shellfish, anchovies, asparagus, mushrooms, and organ meats) are avoided, and other proteins may be limited.

An infant is in the neonatal intensive care unit and has a temperature of 93 °F (33.8 °C). Hypothermia can lead to which of the following clinical manifestations? Metabolic acidosis Metabolic alkalosis Tachycardia Tachypnea

Metabolic acidosis Explanation: Hypothermia can lead to prolonged bleeding, metabolic acidosis, decreased respiratory rates, bradycardia, and cardiopulmonary arrest.

respiratory acidosis

PCO2 *MUST BE* greater than 42 mm Hg PH less than 7.35 & an increase in HCO3 (hypercapnia, hypoventilation)

When evaluating a client's arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? pH 7.48 O2 saturation 95% HCO3 21 mEq/L PaCO2 36

PH 7.48 Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO3 value is below normal. The PaCO2 value and the oxygen saturation level are within a normal range.

Which of the following electrolytes is a major cation in body fluid? Phosphate Potassium Chloride Bicarbonate

Potassium is a major cation that affects cardiac muscle functioning. Chloride is an anion. Bicarbonate is an anion. Phosphate is an anion.

A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action?

Prepare for cesarean birth. Explanation: Fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium-stained amniotic fluid and bradycardia are further signs of fetal distress that warrant cesarean birth. Amnioinfusion is indicated when the only abnormal fetal finding is meconium-stained amniotic fluid. Client repositioning may improve uteroplacental perfusion, but only serve as a temporary measure because the risk of fetal asphyxia is imminent. Oxytocin administration increases contractions, exacerbating fetal stress.

As status asthmaticus worsens, the nurse would expect which acid-base imbalance? Metabolic alkalosis Respiratory alkalosis Metabolic acidosis Respiratory acidosis

Respiratory acidosis Explanation: As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.

A client with emphysema is at a greater risk for developing what acid-base imbalance? Metabolic alkalosis Chronic respiratory acidosis Chronic metabolic acidosis Respiratory alkalosis

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.

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? Vasodilation Bradycardia Increased urine output Tachycardia

Tachycardia. Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration? The client's long history of respiratory problems indicates that he would be unable to absorb oxygen given at a higher rate. The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. The cells in the alveoli are so damaged by the client's long history of respiratory problems that increased oxygen levels and reduced carbon dioxide levels likely will cause the cells to burst. The oxygen will be lost at the client's nostrils if given at a higher level with a nasal cannula.

The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. Explanation: Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide level, they may stop breathing. Oxygen flow rate is not diminished at high levels when administered through a nasal cannula. The client's ability to absorb oxygen administered at a higher level is not affected. Increased oxygen levels and decreased carbon dioxide levels cannot cause cells to burst.

A patient with cancer is being treated on the oncology unit for bilateral breast cancer. The patient is undergoing chemotherapy. The nurse notes the patient's serum calcium level is 12.3 mg/ dL. Given this laboratory finding, the nurse should suspect which of the following statements? The patient's diet is lacking in calcium-rich food products. The patient may be developing hyperaldosteronism. The patient has a history of alcohol abuse. The patient's malignancy is causing the electrolyte imbalance.

The patient's malignancy is causing the electrolyte imbalance. The patient's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium level greater than 10.2 mg/dL (2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia by a variety of mechanisms. The patient's calcium level is elevated; there is no indication that the patient's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Absence of glucose Absence of protein Urine pH of 3.0 Specific gravity of 1.03

Urine pH of 3.0 Explanation: 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 1.002 to 1.035, 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 Dull headache Mental cloudiness Increased pulse

Ventricular fibrillation Explanation: 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.

The nurse is caring for a child with type 1 diabetes mellitus. The nurse notes that the child is drowsy, has flushed cheeks and red lips, a fruity smell to the breath, and there has been an increase in the rate and depth of the child's respirations. The nurse recognizes that these symptoms indicate the child has: insulin reaction. polyphagia. Cheyne-Stokes respirations. diabetic ketoacidosis.

diabetic ketoacidosis. Explanation: Diabetic ketoacidosis is characterized by drowsiness, dry skin, flushed cheeks and cherry-red lips, acetone breath with a fruity smell, and Kussmaul breathing (abnormal increase in the depth and rate of the respiratory movements).

The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis? pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L 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.

A nurse preceptor is working with a student nurse who is administering medications. Which statement by the student indicates an understanding of the action of an antacid? "The action occurs in the esophagus by increasing peristalsis and improving movement of food into the stomach." "The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity." "The action occurs in the large intestine by increasing electrolyte absorption into the system that decreases pepsin absorption." "The action occurs in the small intestine, where the drug coats the lining and prevents further ulceration."

"The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity." Explanation: The action of an antacid occurs in the stomach. The anions of an antacid combine with the acidic hydrogen cations secreted by the stomach to form water, thereby increasing the pH of the stomach contents. Increasing the pH and decreasing the pepsin activity provide symptomatic relief from peptic ulcer disease. Antacids don't work in the large or small intestine or in the esophagus.

A 42-year-old client has chronic hypo natremia, which requires weekly blood labs to keep him from lapsing into convulsions or a coma. What is the level of serum sodium below which convulsions or coma can occur? 147 mEq/L 142 mEq/L 140 mEq/L 135 mEq/L

135

The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be which of the following? 135 mEq/L 125 mEq/L 145 mEq/L 155 mEq/L

155. The patient is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium level higher than 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 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.

When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? Mild confusion Irregular heart rate Blood pressure 96/53 mm Hg Weight loss of 4 lb

2. 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, but following up on potential cardiac dysrhythmias is a higher priority. Confusion may occur with dehydration and hyponatremia, but following up on potential cardiac dysrhythmias is a higher priority. The blood pressure is slightly lower than normal but is not life threatening. Following up on potential cardiac dysrhythmias is a higher priority.

Which of the following may occur with respiratory acidosis? Decreased blood pressure Third spacing Increased intracranial pressure (ICP) Decreased pulse

3. 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. Respiratory acidosis does not result in the fluid shifts known as third spacing.

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 120 mm Hg 84 mm Hg 58 mm Hg 45 mm Hg

84 mm Hg Explanation: In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.

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 7-year-old with a fracture tibia A 65-year-old with a myocardial infarction A 72-year-old with a total knee repair A 52-year-old with diarrhea

A 52 YEAR OLD W/ DIARRHEA

A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, a problem that was accompanied by a random blood glucose reading of 575 mg/dLm (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomena? Risk factor Infection Morbidity Exacerbation

Exacerbation Explanation: This client has experienced a significant exacerbation of his chronic disease (diabetes mellitus), which has manifested as an acute threat to their health. Morbidity is an epidemiological statistic of the frequency of a disease. The client's problem does not have an infectious etiology and while risk factors underlie their present condition, they are not the essence of their current state.

An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? Hyperkalemia Hypernatremia Hypophosphatemia Hypokalemia

Hypokalemia Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a defict in total potassium stores. Potassium-losing diuretics, such as loop diuretics, can induce hypokalemia.

A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? Hyponatremia Hypomagnesium Hypokalemia Hypocalcemia

Hypokalemia Potassium-losing diuretics, such as the thiazides and loop diuretics, can induce hypokalemia. Gastrointestinal (GI) loss of potassium is another common cause of potassium depletion. Vomiting and gastric suction frequently lead to hypokalemia.

Which of the following would be a potential cause of respiratory acidosis? Hyperventilation Diarrhea Hypoventilation Vomiting

Hypoventilation Explanation: Respiratory acidosis is always due to inadequate excretion of CO, with inadequate ventilation, resulting in elevated plasma CO concentration, which causes increased levels of carbonic acid. In addition to an elevated PaCO, hypoventilation usually causes a decrease in PaO.

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? Respiratory alkalosis Metabolic alkalosis Metabolic acidosis Respiratory acidosis

Metabolic acidosis Explanation: 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 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? Suggest a fluid restriction. Offer a prescribed antiemetic medication. Remove the Hemovac. Encourage oral fluids.

Offer a prescribed antiemetic medication. 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 is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure? Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Metabolic acidosis

Respiratory acidosis Explanation: In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure. Understanding the sequence of the pathophysiologic processes in status asthmaticus is important for understanding assessment findings. Respiratory alkalosis occurs initially because the patient hyperventilates and PaCO2 decreases. As the condition continues, air becomes trapped in the narrowed airways and carbon dioxide is retained, leading to respiratory acidosis.

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? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis Explanation: 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.

A 70-year-old man who enjoys good health began taking low-dose aspirin several months ago based on recommendations that he read in a magazine article. During the man's most recent visit to his care provider, routine blood work was ordered and the results indicated an unprecedented rise in the man's serum creatinine and blood urea nitrogen (BUN) levels. How should a nurse best interpret these findings? The man may be experiencing liver toxicity from the aspirin The man may be experiencing a paradoxical effect of aspirin The man may be allergic to aspirin The man may be experiencing nephrotoxic effects of aspirin

The man may be experiencing nephrotoxic effects of aspirin Explanation: Damage to the kidneys is called nephrotoxicity. Decreased urinary output, elevated blood urea nitrogen, increased serum creatinine, altered acid-base balance, and electrolyte imbalances can all occur with kidney damage.

Which physical sensation will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises? blurred vision mental confusion dizziness dyspnea

dizziness Explanation: Hyperventilation occurs when the client breathes so rapidly and deeply that she exhales excessive amounts of carbon dioxide. A characteristic symptom of hyperventilation is dizziness. To avoid hyperventilation, the nurse should assist the client in the practice of slow, deep breathing in a regular breathing pattern. Dyspnea, blurred vision, and mental confusion are not associated with hyperventilation.

The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first: start an intravenous infusion. institute rewarming. prepare for intubation. administer oxygen.

administer oxygen. Explanation: Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fluid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies.

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which prescriptions should the nurse implement first? albuterol nebulizer sputum culture ipratropium inhaler chest x-ray

albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 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 experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be 7.30 7.45 7.50 7.35

7.50 Explanation: 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.

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 Respiratory alkalosis Metabolic alkalosis Respiratory acidosis

Metabolic acidosis Explanation: 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.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Metabolic alkalosis

Metabolic acidosis. 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).

An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? Metabolic alkalosis Metabolic acidosis Hypoglycemia Hyperkalemia

Metabolic alkalosis Explanation: In a client with bulimia nervosa, metabolic alkalosis may occur secondary to hydrogen loss caused by frequent, self-induced vomiting. Typically, the blood glucose level is within normal limits, making hypoglycemia unlikely. In bulimia nervosa, hypokalemia is more common than hyperkalemia and typically results from potassium loss related to frequent vomiting.

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which conclusion would be accurate? The client requires oxygen therapy with very low oxygen concentrations. `The client is severely hypoxic. The client's PaO2 level is within normal range. The oxygen level is low but poses no risk for the client.

`The client is severely hypoxic. Explanation: Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).

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 Respiratory acidosis Respiratory alkalosis Metabolic acidosis

Metabolic alkalosis Explanation: 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 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 acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis

Metabolic alkalosis Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma biacarbonate concentration. The most common cuase of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.

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? Serum sodium level Anion gap PaCO2 Bicarbonate level

Anion gap Explanation: 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.

The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of gastroesophageal reflux? There are recurrent paroxysmal bouts of abdominal pain. In this disorder the sphincter that leads into the stomach is relaxed. A thickened, elongated muscle causes an obstruction at the end of the stomach. A partial or complete intestinal obstruction occurs.

In this disorder the sphincter that leads into the stomach is relaxed. Explanation: Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus, which leads into the stomach, is relaxed and allows gastric contents to be regurgitated back into the esophagus. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, which leads to an obstruction at the distal end of the stomach.

The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? Pancreas and heart Lungs and kidneys Kidneys and liver Heart and lungs

LUNGS AND KIDNEYS 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.

Examination of a client's bladder stones reveals that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet? High protein High sodium Low oxalate Low purine

Low purine Explanation: A low-purine diet is used for uric acid stones, although the benefits are unknown. Clients with a history of calcium oxalate stone formation need a diet that is adequate in calcium and low in oxalate. Only clients who have type II absorptive hypercalciuria—approximately half of the clients—need to limit calcium intake. Usually, clients are told to increase their fluid intake significantly, consume a moderate protein intake, and limit sodium. Avoiding excessive protein intake is associated with lower urinary oxalate and lower uric acid levels. Reducing sodium intake can lower urinary calcium levels.

A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Respiratory acidosis Explanation: This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In metabolic alkalosis, the pH and HCO3- values are above normal.

A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition?

ketoacidosis Explanation: Kussmaul respirations (fast, deep, labored breathing) are common in ketoacidosis. Acetone, which is volatile, can be detected on the breath by its characteristic fruity odor. If treatment is not initiated, the outcome of ketoacidosis is circulatory collapse, renal shutdown, and death. Ketoacidosis is more common in people with diabetes who no longer produce insulin, such as those with type 1 diabetes. People with type 2 diabetes are more likely to develop hyperosmolar hyperglycemic nonketotic syndrome because with limited insulin, they can use enough glucose to prevent ketosis but not enough to maintain a normal blood glucose level.