Prep U: Fluid, Electrolyte and Acid-Base Balance

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr

100 gtt/min

The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply.

100 mL from melted ice chips serving of jello infusion of intravenous solution cup of ice cream

Fluid Volume Deficit (FVD)

A contracted vascular compartment due to loss of ECF or accumulation of fluid in interstitial space Causes: Vomiting/Diarrhea Loss of sodium containing fluids nasogastric suction burns tachypnea *Vomiting/Diarrhea most commom causes*

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

A hypotonic solution

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

Apply pressure to insertion site for at least 3 minutes.

A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client?

Gauze dressing

Hypercalcemia

Higher calcium than normal >10.2 S/S: stomach upset, nausea, vomiting and constipation, muscle weakness and bone pain

Hyperchloremia

Higher chloride than normal >108 S/S: fluid retention high blood pressure muscle weakness, spasms, or twitches irregular heart rate confusion, difficulty concentrating, and personality changes numbness or tingling seizures and convulsions

Hyperphosphatemia

Higher phosphorus than normal >4.5 S/S: muscle cramps, tetany, and perioral numbness or tingling, bone and joint pain, pruritus, and rash.

Arterial Blood Gas (ABG)

Indicates the regulatory mechanism of the lungs or kidneys maintaining pH PO2: normal- 80-100 SAO2: 95% or higher PCO2: 35-45 HCO3: 22-26

Hypocalcemia

Lower calcium than normal <8.2 S/S: paresthesia, muscle spasms, cramps, tetany, circumoral numbness, and seizures.

Hypochloremia

Lower chloride than normal <100 S/S: Fever Difficulty breathing Confusion Swelling‌

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

Remove the IV.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?

Restart infusion in another vein and apply a warm compress.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?

Stop the transfusion immediately.

The nurse is caring for a client who will be receiving multiple antibiotics. When choosing a site for intravenous insertion, which guideline will the nurse follow?

Use distal parts of larger veins where accessible.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:

a winged infusion needle.

A client with dehydration will have an increase in:

aldosterone

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

calcium and phosphorus

The process of filtration begins at the:

glomerulus.

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

hypovolemia

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

low calcium.

Urine Specific Gravity

measures kidney's ability to concentrate urine Range of normal SG: 1.003-1.025 Increase with FVD, Dehydration Decrease with FVE, Overhydration

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure

A decrease in arterial blood pressure will result in the release of:

renin.

A nursing instructor is discussing administration of total parenteral nutrition (TPN) with a nursing student. Which statement by the student would require further teaching?

"I will be sure to change the TPN tubing every other day."

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?

"I've been taking antacids almost every 2 hours over the past several days."

A client who is receiving total parenteral nutrition and lipids asks the nurse why the solution looks like milk. What is the most appropriate nursing response?

"The white milky solution contains lipids, or fat, to provide extra calories."

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

2,500 mL/day

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

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

Fluid Volume Excess (FVE)

Expansion of the ECF as a result of an increase in total body sodium content and in increase in total body water Causes: Heart Failure (HF) Liver disease such as Cirrhosis Kidney failure Nephrotic Syndrome-- disorder that causes excess excretion of protein in the urine

A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?

Flush the IV with 3 mL of normal saline.

A nurse is measuring intake and output for a client who has congestive heart failure. What does not need to be recorded?

Fruit consumption

Hypermagnesemia

Higher magnesium than normal >2.6 S/S: cardiovascular complications (hypotension, and arrhythmias) and neurological disorder (confusion and lethargy). Higher values of serum magnesium (exceeding 15 mg/dL) can induce cardiorespiratory arrest and coma.

Hyperkalemia

Higher potassium than normal >5.0 S/S: heart palpitations, shortness of breath, chest pain, nausea, or vomiting.

Hypernatremia

Higher sodium than normal >145 S/S: excessive thirst, extreme fatigue and lack of energy, and possibly confusion

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

Infants

Hypomagnesemia

Lower magnesium than normal <1.8 S/S: anorexia, nausea, vomiting, lethargy, weakness, personality change, tetany (eg, positive Trousseau or Chvostek sign or spontaneous carpopedal spasm, hyperreflexia), and tremor and muscle fasciculations.

Hypophosphatemia

Lower phosphate than normal <2.5 S/S: Muscle weakness. Softening or weakening of bones. Chronic depletion. Depletion of muscles. Issues with the blood. Altered mental state. Seizures. Numbness.

Hypokalemia

Lower potassium than normal <3.5 S/S: Muscle twitches. Muscle cramps or weakness. Muscles that will not move (paralysis) Abnormal heart rhythms. Kidney problems.

Hyponatremia

Lower sodium than normal <135 S/S: Nausea and vomiting. Headache. Confusion. Loss of energy, drowsiness and fatigue.

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?

Metabolic alkalosis

Hematocrit (Hct)

Normal serum: male: 44-52 female: 39-47 Determines % of RBC's in plasma increases in FVD because RBC's are condensed in smaller plasma volume Decreases in FVE because RBC's are in larger plasma volume

Creatinine

Normal: 0.6-1.2 Renal disease Muscle condition: Rhabdomyolosis--- sudden release of muscle creatinine Meds may increase levels: Cefoxitin, Cimetidine

BUN/Creatinine Ratio

Normal: 10:1 Ratio >10:1: Hypervolemia, low perfusion pressures tp kidney, increased protein metabolism may be present Ratio <10:1: Decreased protein intake, hepatic insufficiency or repeated dialysis When both BUN and Creatinine are increased: Indicates kidney disease

Serum Osmolality

Normal: 280-295 Determined by serum sodium concentration Finding is high in dehydration, hyperglycemia, and presence of elevated BUN Finding is low in overhydration

Albumin

Normal: 3.5-5.0 Decreased serum albumin level causes reduced colloidal osmotic pull in intravascular space, allowing fluid to shift to interstitial space and produce edema

blood urea nitrogen (BUN)

Normal: 8-20 Elevations: trauma, starvation, dehydration, increased protein Decreases: overhydration, low protein consumption

Glomerular Filtration Rate (GFR)

Normal: >60 The kidneys should filter about 180 liters of plasma per day Evaluates how well the kidneys are working

A nurse is preparing a presentation for a group of older adults at a local senior center about the importance of fluid intake. As part of the presentation, the nurse plans to discuss how the intake and output of fluids is typically balanced each day. When describing the normal daily output of fluids, which component would the nurse identify as accounting for the smallest amount of fluid output?

Perspiration

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?

Sodium is regulated by the renin-angiotensin-aldosterone system.

A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?

The pump will continue to infuse fluid even when the needle is displaced.

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

The renal system retains more water.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?

hemolytic transfusion reaction: incompatibility of blood product

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

muscle cramping and tetany