Week 14 Chapter 40: Fluid, Electrolyte, and Acid-Base Balance
The health care provider is concerned that the client has hypokalemia. During the physical examination, which question should the nurse ask the client? "Have you been experiencing chest pain?" "Have you been experiencing muscle weakness or leg cramps?" "Have you been having diarrhea?" "Have you been experiencing difficulty breathing?"
"Have you been experiencing muscle weakness or leg cramps?" Hypokalemia is a potassium deficit. When the level of potassium decreases, potassium moves out of the cells, creating an intracellular potassium deficiency. Typical symptoms include muscle weakness and leg cramps. Hyperkalemia is likely to cause diarrhea. Hypokalemia is not known to cause chest pain or difficulty breathing, unless an arrhythmia occurs due to an imbalance in the potassium level.
While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance? "How much do you typically urinate during the day?" "How often do you usually have a bowel movement?" "How often do you experience leg cramps? "How much coffee do you drink during a typical day?"
"How much do you typically urinate during the day?" Questions and leading statements about fluid balance are part of a comprehensive health history. Urinary output is one factor to consider in fluid balance. Bowel movements, especially if a client is having multiple loose stools a day, may affect fluid balance but is not the most appropriate question to ask. Leg cramps can occur when there is an electrolyte imbalance but is not the most appropriate question. Lastly, coffee can have diuretic-like properties but is also not the most appropriate question to ask to assess fluid balance.
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? extracellular fluid 3.5 cm H2O 5 cm H2O 9.5 cm H2O 12 cm H2O
3.5 cm H2O The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.
A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? Banana Milk Yogurt Turkey
Banana Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? (3.5-5.0) Fluid volume excess Pulmonary embolus Cardiac dysrhythmias Tetany
Cardiac dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.
The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect? Sepsis Phlebitis Infiltration Air embolism
Phlebitis Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.
A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse? Eggs Chicken Apples Spinach
Spinach Sardines, whole grains, and green leafy vegetables also provide calcium.
extracellular fluid
body fluids located outside of cells
A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? cardiac irregularities muscle weakness increased intracranial pressure (ICP) metabolic acidosis
cardiac irregularities Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.
alkalosis
condition, characterized by a proportionate lack of hydrogen ions in the extracellular fluid concentration, in which the pH exceeds 7.45
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? maintenance of cell size maintenance of blood volume transportation of nutrients removal of waste
maintenance of cell size The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.
A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: an access route to administer medications intravenously. replacement of fluids for those lost from vomiting and diarrhea. an access route to replace fluids in combination with blood products. intravenous fluids to be administered on an outpatient basis.
replacement of fluids for those lost from vomiting and diarrhea. The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.
A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply. respiratory muscle weakness confusion ventricular dysrhythmia abdominal distention constipation
respiratory muscle weakness confusion ventricular dysrhythmia *With hypophosphatemia, findings include neuromuscular dysfunction; weakness, especially respiratory muscles; fatigue; myocardial depression; ventricular dysrhythmias; rhabdomyolysis; confusion, coma; decreased oxygen delivery to tissues; renal loss of bicarbonate, calcium, magnesium, and glucose; bone changes (osteomalacia); and endocrine changes (insulin resistance). Abdominal distention and constipation are more commonly associated with hypokalemia.