32: Fluids, Electrolytes, and Acid-Base

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate?

"Granulocytes are a type of white blood cell that can help fight infection." Granulocytes are a type of white blood cell that are used to fight infection. All other options are incorrect statements related to granulocytes.

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 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.

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

"I should drink 2,500 mL/day of fluid." In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.

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." Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.

The nurse is assessing a client who was hospitalized due to a fall with a brief loss of consciousness. Which sign(s) alerts the nurse that the client is severely dehydrated? Select all that apply.

- The client has dark-colored urine with a noticeable odor. - The client reports dizziness when standing up from a chair. - The client has been working outside in warm temperatures. Signs of severe dehydration or hypovolemia can include having concentrated, dark-colored urine that can carry an odor, due to the high specific gravity. Dizziness when changing positions caused by postural hypotension, a condition that results from a rapid drop in blood pressure when standing from sitting or sitting up from lying down, can happen when the client is experiencing a fluid volume deficit secondary to severe dehydration as a result of lower blood volume in circulation. Any client who works outside in warm temperatures is at risk for dehydration. The combination of activity with warm temperatures leads to increased insensible fluid losses through sweat and respiration. A client with severe dehydration would report having a dry mouth with reduced saliva production. A weight loss of 3 lb (1.4kg) over 2 weeks is not considered concerning or indicative of severe dehydration. A client who has lost over 2 lb (2.8 kg) over 24 hours, however, would indicate severe dehydration. A weight loss of 9% to 15% of body weight over a short period of time could indicate severe fluid volume deficit.

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

1+ The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?

2,600 mL The average adult daily fluid source is: 1,300 mL from ingested water, 1,000 mL from ingested food, and 300 mL from metabolic oxidation, totaling 2,600 mL fluid.

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

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?

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 preparing to measure jugular venous distention in a client. To ensure accuracy, the nurse would elevate the head of the client's bed to:

45 degrees When measuring jugular venous distention, the nurse would elevate the head of the client's bed to 45 degrees so that the sternal angle is 5 cm above the right atrium. Any other elevation would lead to inaccurate results.

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O?

55-year-old with congestive heart failure on furosemide Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O.

A nurse is reviewing the arterial blood gas results of a client. Which pH value would the nurse document as indicating acidosis?

7.30 The normal pH ranges from 7.37 to 7.43. A pH of 7.30 indicates acidosis while a pH of 7.47 indicates alkalosis. A pH of 7.37 or 7.41 would be within normal limits.

What is the initial purpose of the action in which the nurse is engaging, during the preparation for the administration of a prescribed IV solution?

Allowing for effective access to the solution Inserting the spike punctures the seal in the IV container and allows access to the contents. Inverting the container allows easy access to the entry site. Touching the opened entry site on the IV container and/or the spike on the administration set results in contamination and the container/administration set would have to be discarded. The action demonstrated is not associated with the need for additional staff.

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?

Apricots Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level.

Which is a common anion?

Chloride Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

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. If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema?

Elevate the legs Edema is a characteristic sign of fluid volume excess (hypervolemia). To reduce edema, the nurse should encourage movement, elevate the legs, stroke the legs using light pressure to encourage movement of fluid back toward the heart, and apply compression stockings to encourage movement of fluid back toward the heart. In addition, the reduction of salt in the diet may decrease edema.

A health care provider writes a prescription to "force fluids." What will be the first action the nurse will take in implementing this prescription?

Explain to the client why this is needed. Several techniques are recommended to help the client drink greater than average amounts of fluids. The nurse should begin by explaining to the client in understandable terms the rationale for the increased fluids and the specific goal of taking the daily amount of fluids prescribed. The largest amount of fluid should be consumed during the day to decrease night wakings to void. It is not necessary for the nurse to decide how much fluid to increase every 8 hours.

Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?

Infants have more total body fluid and ECF than adults. An infant has considerably more total body fluid and ECF than an adult does. Because ECF is more easily lost from the body than ICF, infants are more prone to fluid volume deficits. Because infants' main food is from breast milk or formula, typically infants drink more than adults.

A client has the following arterial blood gas results: pH: 7.33 PaCO2: 42 mm Hg HCO3: 19 mEq/L (19 mmol/L) PaO2: 95 mm Hg Which imbalance would the nurse suspect?

Metabolic acidosis The results reveal metabolic acidosis, which is characterized by a pH lower than 7.35 and a plasma HCO3 concentration lower than 22 mEq/L (22 mmol/L). Respiratory acidosis is indicated by a low pH accompanied by an increased arterial concentration of carbon dioxide, which often is clinically defined as a PaCO2 of greater than 45 mm Hg. Respiratory alkalosis is present when a high pH is accompanied by a blood carbon dioxide concentration lower than 35 mm Hg. Metabolic alkalosis is characterized by a pH higher than 7.45 and a plasma HCO3 concentration above 26 mEq/L (26 mmol/L).

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium?

Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L). Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently. Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

Offer the client sugar-free candy to help combat thirst. To minimize thirst for clients on fluid restriction, offer sugar-free candy and gum to help minimize thirst. Salty or very sweet fluids should be avoided. Rinsing the mouth with water and then having the client spit it out before swallowing may be helpful. Alcohol-based mouthwashes should be avoided because they have a drying effect. A water-based gel, not petroleum based, can be applied to the client's lips to moisten and prevent drying and cracking.

A group of nursing students is reviewing information about the body's electrolytes. The students demonstrate understanding of the material when they identify which electrolyte as having a reciprocal relationship with calcium?

Phosphorus Calcium and phosphorus typically show a reciprocal relationship such that an increase in one leads to a decrease in the other. Sodium is the major cation in the extracellular fluid. Sodium, potassium, and magnesium do not share a relationship with calcium.

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. The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?

Risk for Deficient Fluid Volume An appropriate nursing diagnosis for a client taking a diuretic that increases urinary output would be Risk for Deficient Fluid Volume. The nurse would educate the client on the symptoms of dehydration, how to increase fluid intake, and the need to maintain a record of daily weights. Diuretics do not affect elimination or cause urinary retention. In addition, diuretics do not affect the skin.

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

Sodium is regulated by the renin-angiotensin-aldosterone system. Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

Start an IV of normal saline as prescribed. To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

Stop the transfusion. Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?

Tighten the roller clamp to stop the infusion. The priority nursing action is to tighten the roller clamp on the tubing as this action prevents forward movement of air. All other options are appropriate to remove the air once the tubing has been clamped.

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. Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the reabsorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform?

Weigh the client's wet linen or dressing. In cases in which accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, or dressings and subtracts the weight of a similar dry item. The nurse does not weigh the client without soiled incontinence pads. The nurse does not weigh the client before and after meals to obtain an accurate assessment of the fluid output.

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 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.

The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which will the nurse document on the I&O record? Select all that apply.

client drinking milk client's urination vomiting infusion of intravenous solution The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.

By which route do oxygen and carbon dioxide exchange in the lung?

diffusion Oxygen and carbon dioxide exchange in the lung's alveoli and capillaries by diffusion. Diffusion is the tendency of solutes to move freely throughout a solvent by moving from an area of higher concentration to an area of lower concentration.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

fluid volume excess. A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess.

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance?

hypokalemia All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia.

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find?

hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

hyponatremia. Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

A client has metabolic (nonrespiratory) acidosis. Which type of respirations would be assessed?

increased depth and rate Metabolic (nonrespiratory) acidosis is a proportionate deficit of bicarbonate in the ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate. The lungs attempt to increase the excretion of carbon dioxide by increasing the rate and depth of respirations.

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address?

increased hydrostatic pressure The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by:

increasing ventilation through the lungs. The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. To compensate for respiratory alkalosis, the kidneys increase the excretion of HCO3− to the urine. Kidneys compensate for respiratory acidosis by increasing the excretion of H+ ion into the urine. The kidneys respond to metabolic alkalosis by retaining acid and excreting HCO3−.

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 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 client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?

plasma The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells. Albumin pulls third-spaced fluid by increasing colloidal osmotic pressure but does not restore clotting factors. The infusion of granulocytes improves the ability of the body to overcome infection. Normal saline is an isotonic solution that replaces fluid loss but does not replace clotting factors.

A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action?

wear gloves, hold IV catheter in place, and gently remove the tape The nurse should carefully remove the tape from the outside to the insertion point while supporting the catheter. Gloves should be worn.