Week 1 Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances Lewis: Medical-Surgical Nursing, 10th Edition
what is an easy way remember system specific assessments when the client has hypokalemia?
-CRAMPS- -COMPLICATIONS with GI losses-vomiting, NG suctioning- constipation -REFLEXES decrease, respiration shallow and decreased -ARRHYTHMIAS-ECG changes; inverted/flat T waves no K+ for repolarization -Abdominal distention; alkalosis; anxiety followed by confusion and eventually a coma -MUSCLE; cramps; muscle weak; skeletal muscle weak; monitor I&O -PULSE; irregular and weak, lowered BP -SERUM K+ <3.5
what is an easy way to remember system specific assessments when the client has hypokalemia?
-DEATH- -DYSRHYTHMIAS-irregular rhythm, bradycardia -ECG- changes- tall peaked T waves -ABDOMINAL cramping; diarrhea -THE muscles twitch -HYPOTENSION; has irritability/restlessness
what is an easy way to remember system specific assessments when the client has hypernatremia secondary to fluid deficit?
-DRIED- -DRYNESS of mucous membranes, concentration in urine, decreased urine output -RED, flush skin, restless, progressing to confusion, increase serum Na+ >145 -INCREASED temperature, I&O, increase concentration in urine and decrease output -ELEVATED HR -DECREASED weight; decreased BP, decrease CVP, decrease urine output
what is an easy way to remember system specific assessment when the client has hypernatremia secondary to fluid retention?
-EDEMA- -EDEMA -DECREASE in the hematocrit; diet increase Na+ -ELEVATED weight; elevated BP and HR -MENTATION decreased -lethargic -A flushing of skin; assess lab serum Na+ >145
what is an easy way to remember the "first do priority nursing interventions" for a client with hypokalemia?
-POTASSIUM- -POTATOES, avocados, banana, oranges, broccoli, tomatoes raises K+ -ORAL potassium supplements -T waves depressed or flattened-monitor -ARRHYTHMIAS-monitor -SHALLOW ineffective respirations- monitor -SOUNDS of breathing diminished-monitor -IV supplement is never given an IV push-never IM or SQ -URINE output and intake-monitor -MUSCLE cramping, muscle weakness-fall prevention, motility-GI decreased, monitor K+ and digitalis level- low serum K+ can potentiate digitalis toxicity.
List foods high in potassium
-POTATOES, avocados, banana, oranges, broccoli, tomatoes
what is an easy way the "First Do Priority Nursing Interventions" for a client with hypernatremia?
-RESTRICT- -RESTICT fluid intake if experiencing fluid retention- remember oral hygiene, restrict foods high in sodium -EVALUATE for cerebral changes such as headaches, nausea, evaluate for seizures and initiate seizures precautions -STRICT intake and output; safety- falls -THE blood pressure is elevated -fluid excess; the BP is low for hemo-concentrated Na+- fluid deficit; VS need to be monitored. -REVIEW origin of hypernatremia -IF there is a fluid deficit; administer hypotonic IV fluids for fluid loss- hypertonic dehydration. if the client is in shock or requires fluid challenges to administer- isotonic fluids. these will prescribe by the health care provider. ENCOURAGE FLUID INTAKE AND DISCOURAGE SODIUM INTAKE. -CHECK daily weight; neurological assessments -THE excess fluid may be removed by diuretics
what is an easy way to remember the First-do priority nursing interventions for a clients with hypocalcemia?
-SAFE- -SEIZURE precautions -ADMINISTER calcium supplements -FOODS high in calcium-dairy, green- educate client -EMERGENCY equipment on standby; monitor
what is an easy way the "First Do Priority Nursing Interventions" for a client with hyponatremia?
-SODIUM- -SEIZURE precautions -OCCURS in Addison disease, diabetic acidosis, and renal disease; clients whom NPO; SIADH; perspiring, vomiting, diarrhea; burn, or excess administration of D5W -DAILY weight; diet foods high in Na+ if the cause is low Na+ intake -IF retaining fluids, restrict fluid. restrict fluids; irrigate NG tube with NS -UNDERSTAND the cause; use hypertonic fluids if sever; isotonic if moderate- 0.9% NS, or if need to restore the ECF volume. -MONITOR vital signs -temp, HR, RR, BP, I&O; weight is one of the best indicators of fluid status; skin turgor; monitor GI changes-hyperactive bowel sounds, increased GI motility, abdominal cramping, anorexia, nausea, vomiting- and neurological assessment-pupils, LOC, headache- safety - fall precautions; change positions slowly.
what is an easy way to remember the "first do priority nursing interventions" for a client with hyperkalemia?
-STOPS- -STOP infusion of IV potassium -TALL T waves-peaked, widened QRS, prolonged PR interval-monitor ECG; monitor K+ levels ongoing; take VS with a focus on HR and BP -ORDERS; Kayexalate or dextrose with regular insulin -PROVIDE potassium restricted foods, potassium-losing diuretics -Lasix -SALT substitutes NOT allowed
list medication that can cause hyperkalemia?
-angiotensin-converting enzyme inhibitors, -potassium-sparing diuretics spironolactone-Aldactone -digoxin -heparin -nonsteroidal antiiflammatory drugs
list foods high in sodium
-bread -cold cuts and cured meats -pizza -poultry -soup -sandwiches -milk -cheese -condiments
list medication that can cause hypokalemia?
-diuretics such as furosemide-Lasix and thiazides -corticosteroids -insulin -adrenergics, such as epinephrine and albuterol -amphotericin B
list foods high in calcium
-leafy green vegetables -salmon -cheese -dairy -intake of whole grains -tuna
list causes of hypocalcemia
-low Ca+ rich food in diet -renal failure -hypoparathyroidism
list reasons why elderly can develop hyperkalemia?
-renal function deteriorates with the aging process -elimination is decreased due to decrease in oral fluid intake -note that the plasma renin activity and aldosterone levels also decrease with age -alteration in the renal blood flow -likely to take meds that interfere with potassium excretion
what are intervention that apply to both hyper and hyponatremia
-seizure precautions -daily weight -intake and output
what is and easy way to remember the First-do priority nursing intervention for a clients with hypercalcemia?
-the 7 F's- -FLUIDS- 0.9% NS IV- to promote excretion; acid-ash fluids-prune, cranberry juice-to reduce risk for renal calculi formation -FUROSEMIDE-Lasix -FOODS low in calcium -FOCUS on VS, neurological assessment; safety precautions due to confusion -FALL precautions due to confusion -FRACTURES-monitor for pathologic
what is an easy way to remember system specific assessment when the clients has hypercalcemia?
-the fat cat: CALCIUM- -CARDIAC dysrhythmias: decrease QT interval and decrease or shortened ST segment; CNS depression -ANOREXIA, nausea; constipation -LOC decreased -CALCIUM level > 10.5 mg/dl -INCREASE in drowsiness -UNDERACTIVE reflexes -MUSCLE weakness
what is an easy way to remember system specific assessment when the client has hypocalcemia?
-the skinny cat: TWITCH- -TROUSSEAUS sign -head finger spasms-with sustained BP cuff inflation; tingling-numbness-extremities, circumoral. -WATCH for dysrhythmias-decrease pulse, prolonged QT and ST segments-ECG -INCREASE in bowel sounds; diarrhea -TETANY, twitching, tingling-circumoral, extremities- seizures; spasms at rest than can progress to tetany -CHVOSTEK'S sign -facial twitching -HYPOTENSION, hyperactive DTR
what are examples of hypotonic IV fluid?
0.45% NS
what are examples of isotonic IV fluid?
0.9% NS Lactated Ringers
which clinical findings is a priority for indicating the client is experiencing fluid volume excess? 1-BP change from 108/78 to 140/90 2-decreased crackles in lower lung fields 3-pulse increased form 72/min to 80/min 4-weight from 150 lbs to 151 lbs
1-BP change from 108/78 to 140/90
which of these clients would be high risk for fluid overload? select all that apply 1-a client who is in chronic renal failure 2-a client with cystic fibrosis 3-a client who is in heart failure 4-a client with diabetes mellitus and has hyperosmolar hyperglycemic nonketotic syndrome (HHNS) 5-a client with Crushing disease
1-a client who is in chronic renal failure 3-a client who is in heart failure 5-a client with Crushing disease
what assessment finding should be reported to the provider of care for a client who is taking bumetanide (Bumex) who has a serum potassium level of 3.0? 1-a flattened or inverted T wave 2-an elevated ST segment 3- a prolonged PR interval 4-hyperreflexia
1-a flattened or inverted T wave
what clinical finding is a priority to report to the healthcare provider for a client who has been presenting with diarrhea for the last 48 hours from an unknown etiology? 1-arterial blood gas of pH-7.31'PaCO-35; HCO-20 mEq/L 2-arterial blood gas of pH-7.46; PaCO-45; HCO-27mEq/L 3-trousseau's sign 4-shallow breathing
1-arterial blood gas of pH-7.31'PaCO-35; HCO-20 mEq/L
what is the priority of care for a client who presents with the following ABG report: pH-7.48, PaCO- 33 mmHG, HCO-23 mEq/L? 1-assist client to slow down breathing and assist with rebreathing device 2-notify the healthcare provider about the arterial blood gas report interpreted as respiratory acidosis 3-place in high-fowlers and encourage deep breathing and coughing 4-place in the prone position to prepare for respiratory therapy.
1-assist client to slow down breathing and assist with rebreathing device
which documentation indicates an understanding of how to position a client who is experiencing fluid overload from too much IV fluid and is presenting with dyspnea, R-38, HR-120 bpm, extremely anxious, and crackles throughout lung fields? 1-client positioned in the high fowlers position 2-client positioned in the lithotomy position 3-client positioned in the supine position 4-client positioned in the sim's position
1-client positioned in the high fowlers position
which of these medications should be questioned regarding the appropriateness for a client who has calcium level of 6.1? 1-furosemide(Lasix) 2-hydrochlorothiazide (HCTZ) 3-vitamin A 4-vitamin B
1-furosemide(Lasix)
what is the priority nursing interventions for a client with a serum sodium level 128 1-have suction at the bedside 2-encourage water intake to 2000 ml/day 3-question order for IV for Normal saline 4-restrict cheese and condiments
1-have suction at the bedside
which of these clinical findings indicate a client has a magnesium level of 3.0 1-hyporeflexia 2-tetany 3-trousseaus 4-twitching
1-hyporeflexia
which of these assessment findings would be most consistent with a serum sodium level 128 1-hypotension 2-constipation 3-weight increase 4-decreased DTRs 5-hyperactivity
1-hypotension 4-decreased DTRs
which of these statements made by the client indicates a need for further teaching to a client with a potassium level of 5.2? 1-i will drink orange juice each time take my medications throughout the day. 2-i will stop using salt substitutes with my meals 3-i can continue to take my bumetanide (Bumex) as prescribed. 4-i will not continue taking my NSAIDS as prescribed until I get my next blood work back
1-i will drink orange juice each time take my medications throughout the day.
which of these actions by the LPN would require intervention by the change nurse to further educate a LPN about the appropriate standard of care for a client with serum sodium of 133? 1-irrigates the NG tube with tap water 2-assists the UAP in obtaining the daily weight 3-due to poor sodium intake reviews food good for snacks as milk and cheese 4-discusses with the client the importance of changing positions slowly when getting up from lying down
1-irrigates the NG tube with tap water
which of these statements made by the client indicates and understanding of the physiology of magnesium? 1-magnesium is mostly found in bones 2-magnesium is responsible for regulating calcium in the body 3-magnesium stimulates the production of the parathyroid hormone 4-monitor for hypertension
1-magnesium is mostly found in bones
which one of these lab values might indicate a complication for a client with a NG tube that has been set to low suction for 24 hours? 1-pH-7.48; PaCO-35;HCO-28 2-pH-7.45; PaCO -36; HCO-25 3-pH-7.33; PaCO-48;HCO-25 4-pH-7.33; PaCO-36; HCO-21
1-pH-7.48; PaCO-35;HCO-28
what is the priority of care for a client with a sodium level of 132, BP-150/90, weight gain of 2 lbs in last 24 hours and has an order to push PO fluids? 1-review the plan with the UAP 2-develop a plan for the UAP to administer 60 mL of oral fluids per hour 3-notify the provider of care and verity order 4-review the importance of recording weight every 48 hours
3-notify the provider of care and verify order
what is the priority of care for a client who had a thoracotomy 12 hours ago and is on 40% humidified oxygen with the following ABG result: PaO-90%, pH-7.30 PaCO 48 mmHG; HCO-26 mEq? 1-position in high-fowlers and encourage coughing and deep breathing 2-place in the prone position to prepare for respiratory therapy 3-notify the healthcare provider about the report and expect an order to increase oxygen percentage 4-administer anti-anxiety agent, and assist the client with a rebreathing device to increase oxygen level
1-position in high-fowlers and encourage coughing and deep breathing
what would be the priority nursing intervention for a client with a BP change from 140/88 to 86/62? 1-put client in supine position with legs elevated 2-notify provider of care 3-put client in fowlers position 4-evaluate characteristics of mucous membranes
1-put client in supine position with legs elevated
which one of these nursing actions is the priority for a client who was admitted for vomiting 24 hours and presents with the ABG results pH-7.48;PaCO-45; HCO-29? 1-the UAP weighs the client daily 2-the LPN irrigates the NG tube with tap water 3-the RN administer oxygen via a rebreathing device per protocol. 4- the RN administers sodium bicarbonate per protocol
1-the UAP weighs the client daily
what is the normal serum sodium level?
135-145 mEq/L
what is the priority of care for a young female client in her 37th week of pregnancy who continues to breathe at 32/min. and is presenting with this ABC report: pH-7.47; PaCO-32 mmHg; HCO-24mEq/L? 1-administer the oxygen supplement per protocol 2-assist client to show down breathing and assist with rebreathing device 3-reposition every 2 hours and encourage coughing and deep breathing 4-notify the healthcare provider about the arterial blood gas report interpreted as respiratory acidosis
2-assist client to show down breathing and assist with rebreathing device
which nursing action would be the priority for a client who orthopnea, dyspnea, and bibasilar crackles in lungs with auscultation? 1-elevate legs to promote venous return 2-decrease the IV fluids and notify the provider of care 3-orient the client to time, place, and situation. 4-prevent complication of immobility
2-decrease the IV fluids and notify the provider of care
which of these assessment findings are important to monitor for a post-op client who is presenting with a pH-7.32;PaCO-35; HCO-21? select all that apply 1-BP-160/100 2-diarrhea 3-shallow breathing 4-dysrhythmia 5-drowsy and disoriented
2-diarrhea 4-dysrhythmia 5-drowsy and disoriented
what would be the priority of care for an older adult client who is presenting with edema, tachycardia, and acute confusion? 1-check skin turgor and thirst 2-evaluate trends in the daily weight 3-monitor the I&O 4-turn and reposition every shift
2-evaluate trends in the daily weight
which one of these clinical findings is the priority to the healthcare provider for a client with a calcium level of 7.1? 1-constipation 2-facial twitching with tapping on the facial nerve 3-hypoactive bowel sounds 4-lethargy with weakness
2-facial twitching with tapping on the facial nerve
which nursing intervention is the priority for a client with a serum sodium of 152 1-administer IV fluids 0.9% sodium chloride as ordered 2-place suction at the bedside 3-monitor I&O 4-limit water intake
2-place suction at the bedside
which one of these nursing actions is the priority for a client prior to the nurse performing an arterial blood gas on client? 1-evaluate the trousseau's sign by using a sustained BP cuff and inflating it. then evaluate for tingling/numbness of the extremity. 2-the nurse compresses ulnar and radial arteries simultaneously while instructing client to form a fist. have the client relax hand while releasing pressure on radial artery. 3- nurse evaluate the reflex by using the reflex hammer 4-apply a tourniquet above the site where the nurse want to draw the blood.
2-the nurse compresses ulnar and radial arteries simultaneously while instructing client to form a fist. have the client relax hand while releasing pressure on radial artery.
Normal HCO3 levels
22-26 mEq/L
which of these assessment finding would be most important to report to the healthcare provider for a client with serum sodium of 147? 1- dry mucous membranes 2- complaints of being thirsty 3- urine output drop fro 95ml/hr to 40 ml/hr 4-skin warm to touch
3- urine output drop fro 95ml/hr to 40 ml/hr
which assessment findings would a client present with who has been vomiting and experiencing diarrhea for 48 hours? select all that apply 1-blood pressure increased from 110/80 to 135/85' 2-skin temperature hot 3-complaints of syncope when standing up 4-heart rate from 88bpm to 48bpm 5-decrease in skin turgor
3-complaints of syncope when standing up 5-decrease in skin turgor
which documentation indicates the nurse understands how to provide safe care for a client with a serum potassium 3.3? 1-administer potassium chloride IV push 2-hold oral potassium supplement due to level 3-discussing including oranges, bananas, and potatoes in diet 4-verifies with the healthcare provider the appropriateness of a new order to add potassium to IV bag
3-discussing including oranges, bananas, and potatoes in diet
what would be the priority lab value to report for a client with food poisoning and is presenting with abdominal pain, cramping, palpitation, and muscle weakness? 1-magnesium- 1.5 2-sodium -145 3-potassium-3.1 4-calcium-9.4
3-potassium-3.1
which of these clinical findings should the nurse report to the healthcare provider for a client with calcium level of 7.4? 1-drowsy 2-depressed reflexes 3-prolonged ST segment 4-decreased QT interval
3-prolonged ST segment
which nursing intervention would be most appropriate to delegate to the unlicensed assistive personal for a client with a serum sodium of 148 1-restrict PO water intake 2-evaluate effectiveness of diuretic 3-provide oral hygiene every 2-4 hours 4-provide a snack of cracker and cheese
3-provide oral hygiene every 2-4 hours
which one of these statements made by a new graduate indicates the charge nurse was effective when conducting an orientation program for the graduates regarding the pathophysiology behind acid-base balance? 1-metabolic acidosis can occur from diuretic therapy due to the base excess 2-metabolic alkalosis can occur from a prolonged episode of diarrhea 3-respiratory acidosis can occur from depression of the respiratory system from the use of opioids 4-respiratory alkalosis can occur from hypoventilation due to post-operative pain
3-respiratory acidosis can occur from depression of the respiratory system from the use of opioids
which of these foods should be discussed with a client who has a magnesium level of less than 1.3. select all that apply. 1-milk 2-orange juice 3-sandwich on whole grain bread 4-nuts 5-seafood
3-sandwich on whole grain bread 4-nuts 5-seafood
which of these statements by the client indicates an understanding of how the parathyroid hormone (PTH) assists in the body's regulation of calcium? 1-the parathyroid hormone works by increasing the release of PTH when the calcium in the blood is high. 2-the parathyroid hormone works by keeping the calcium in the bones and decreases the absorption 3-the parathyroid hormone pulls out calcium from the bones and promotes the transfer of calcium into the plasma. 4-the parathyroid hormone works by releasing PTH in response to the serum pH.
3-the parathyroid hormone pulls out calcium from the bones and promotes the transfer of calcium into the plasma.
what is the normal serum potassium level?
3.5-5.0 mEq/L
Normal PaCO2 range
35-45 mm Hg
which of these orders is the priority plan for a client who has a sodium level of 148? 1-administer sodium polystyrene sulfonate (Kayexalate) 2- administer sodium bicarbonate as prescribed. 3-administer 3% sodium chloride as prescribed. 4-administer 0.45% normal saline IV fluids as prescribed.
4-administer 0.45% normal saline IV fluids as prescribed.
which of these clinical findings should be reported for a client with a diagnosis of parathyroid disease and presenting with calcium level of 6.0? 1-depressed patellar reflex 2-paresthesia in the hand is produced when tapping over median nerve at the wrist crease. 3-foot extension of the big toe while fanning the other toes when stimulating the outside of the sole of the foot. 4-carpopedal spasm after BP cuff is inflated above systolic pressure
4-carpopedal spasm after BP cuff is inflated above systolic pressure
which of these findings should the nurse report for a client with a magnesium level of 1.1? 1-depressed reflexes 2-drowsiness 3-hypotension 4-depressed ST segment
4-depressed ST segment
what would be the priority plan for a client with a calcium level of 11? 1-decrease client activity level 2-discourage the intake of fiber 3-encourage milkshakes for snacks 4-encourage fluids
4-encourage fluids
which of these laboratory values for a febrile client with pneumonia would indicate a complication with dehydration? 1-decrease in serum osmolarity 2-decrease in serum sodium 3-decrease in BUN 4-increase in urine specific gravity
4-increase in urine specific gravity
which one of these clinical findings would the nurse document and report, indicating a problem with a client who has Guillain-Barre and who developed a respiratory infection 48 hours ago? 1-pH-7.45; PaCO-36 mmHg; HCO-25mEq/L 2-pH-7.50; PaCO-31; HCO-23 mEq/L 3-pH-7.52; PaCO-35; HCO-28mEq/L 4-pH-7.32;PaCO-49 mmHg; HCO-26mEq/L
4-pH-7.32;PaCO-49 mmHg; HCO-26mEq/L
which system-specific assessment finding for a client who has been vomiting for 24 hours would indicate a need for further intervention? 1-BP increase from 110/70 to 130/80 2-urine output decrease from 95 ml/hr to 75 ml/hr 3-BUN-15 4-pulse increase from 68/min to 118/min
4-pulse increase from 68/min to 118/min
what would be the priority lab value to report to the healthcare provider for a client who has and IV infusing of 0.9% NaCL at 115ml/hr; has NG tube to suction, a colostomy and it becoming restless? 1-creatinine-1.2 2-hemoglobin-14 Hematocrit 58% 3-specific gravity of urine-1.029 4-serum sodium-153
4-serum sodium-153
which one of these actions by the new graduate indicates an understanding of how to safely manage the care for a client with a K+ 5.2? 1-monitors for flat T waves on the ECG monitor 2-encourages client to use a salt substitute with food 3-administer an ace inhibitor after assessing the clients BP 4-verifies with the healthcare provider the appropriateness of a new order to add potassium to IV bag
4-verifies with the healthcare provider the appropriateness of a new order to add potassium to IV bag
which of these nursing actions included in the quality assurance program for clients in heart failure would be most appropriate to delegate to the unlicensed assistive personnel? 1-assess breath sounds and check for edema daily 2-check charts to make certain clients are receiving verapamil (calan) as ordered. 3-review all medication with the client every other day 4-weigh all resident as ordered
4-weigh all resident as ordered
Normal pH of blood
7.35-7.45
what is the normal serum calcium level?
8.5-10.5 mg/dL
A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer 3% saline at 50 mL/hr for a total of 200 mL. c. Administer IV morphine sulfate 4 mg every 2 hours PRN. d. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
A (Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.)
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Skim milk c. Mixed green salad b. Grape juice d. Fried chicken breast
A (Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in phosphate and are not restricted.)
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds c. Peripheral pulses b. Urinary output d. Peripheral edema
A (Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.)
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Digoxin (Lanoxin) 0.25 mg/day b. Metoprolol (Lopressor) 12.5 mg/day c. Ibuprofen (Motrin) 400 mg every 6 hours d. Lantus insulin 24 U subcutaneously every evening
A (Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.)
A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? a. Daily alcohol intake b. Dietary protein intake c. Multivitamin/mineral use d. Over-the-counter (OTC) laxative use
A (Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels.)
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis c. Respiratory acidosis b. Metabolic alkalosis d. Respiratory alkalosis
A (The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.)
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake? a. "Drink more fluids in the late evening." b. "Increase fluids if your mouth feels dry." c. "More fluids are needed if you feel thirsty." d. "If you feel confused, you need more to drink."
B (An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.)
A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor c. Urine output b. Daily weight d. Edema presence
B (Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.)
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium level of 120 mg/dL c. Reported weight gain of 2.2 lb (1 kg) d. Urinary output of 280 mL during past 8 hours
B (Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.)
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.
B (IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.)
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate? a. "The prescribed infusion can be given more rapidly when the patient has a central line." b. "The hypertonic solution will be more rapidly diluted when given through a central line." c. "There is a decreased risk for infection when 25% dextrose is infused through a central line." d. "The required blood glucose monitoring is based on samples obtained from a central line."
B (The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.)
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor c. Confusion b. Edema d. Restlessness
B (The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.)
A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action? a. Assign the patient to a semi-private room. b. Assign the patient to a room near the nurse's station. c. Place the patient in a room nearest to the water fountain. d. Place the patient on telemetry to monitor for peaked T waves..
B (The patient should be placed near the nurse's station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.)
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Urine output is 30 mL/hr. b. Blood pressure is 90/40 mm Hg. c. Oral fluid intake is 100 mL for the past 8 hours. d. There is prolonged skin tenting over the sternum.
B (The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypo perfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.)
What is Trousseau's sign?
BP cuff inflated and causes a carpal spasm. (Low calcium)
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% c. Decreased peripheral edema b. Absence of skin tenting d. Blood pressure 110/72 mm Hg
C (Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.)
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."
D (Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.)
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Recommend the patient avoid drinking orange juice with meals. d. Suggest that the health care provider order a basic metabolic panel.
D (Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.)
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis c. Respiratory acidosis b. Metabolic alkalosis d. Respiratory alkalosis
D (The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.)
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Encourage the patient to take deep slow breaths. c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Administer the prescribed normal saline bolus and insulin.
D (The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.)
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseau's and Chvostek's signs. d. Encourage fluid intake up to 4000 mL every day.
D (To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.)
what are examples of hypertonic IV fluid?
D5 .45 NS 3% sodium chloride
list causes of hypercalcemia
Dietary Renal impairment (thiazide diuretics) Malignant bone tumors, fractures, prolonged immobilization Hyperparathyroidism (promotes release of Ca from bone) Steroids
What is Chvostek's sign?
Tap on facial nerve and get a twitch with low Ca.
what will happen to the T wave if a client is presenting with hypokalemia?
flatten out or become inverted.
what labs equal hyponatremia
serum sodium < 135 serum osmolarity < 280
what labs equal hypernatremia
serum sodium >145 serum osmolarity >300
