356: nutrition & hydration/ fluid & electrolyte/ AB
The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank.
30 ml The hemodialysis client has severe renal insufficiency and requires fluid restriction. Clients receiving hemodialysis are limited to a fluid intake resulting in a gain of no more than 0.45 kg (1 lb) per day on the days between dialysis and a daily intake of 500 to 750 mL plus the volume lost in urine. The client consumed a total of 24 oz of fluid (8 oz at breakfast, 8 oz with medications, and 4 oz at lunch and dinner). This equals 720 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 0800 and 50 mL at 1400). The total fluid intake is 820 mL. The client voids approximately 100 mL of urine a day so add that to the prescribed daily intake (750 plus 100 equals 850 allowable daily fluid intake). So, if the client drank 820 mL and is allowed 850 mL, subtract 820 from 850. The client may drink 30 mL more fluid this day.
The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? a) A client with an ileostomy b) A client with heart failure c) A client on long-term corticosteroid therapy d) A client receiving frequent wound irrigations
a) A client with an ileostomy A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.
The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? a) Daily weight b) Urinary output c) IV fluid intake d) NG tube intake
a) Daily weight Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.
The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? a) Malnutrition b) Renal insufficiency c) Hypoparathyroidism d) Tumor lysis syndrome
a) Malnutrition The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.
The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? a) Pour the aspirate into the NG tube through a syringe with the plunger removed. b) Dilute with water and inject into the NG tube by putting pressure on the plunger. c) Discard properly and record as output on the client's intake and output (I&O) record. d) Mix with the formula and pour into the NG tube through a syringe with the plunger removed.
a) Pour the aspirate into the NG tube through a syringe with the plunger removed. After checking residual feeding contents, the gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water and should not be discarded.
A potassium level of 4.5 mEq/L (4.5 mmol/L) is within normal range. A sodium level of 132 mEq/L (132 mmol/L) is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) rather than water should be used for gastrointestinal irrigations because it is an isotonic solution. a) Prolonged bed rest b) Renal insufficiency c) Hyperparathyroidism d) Excessive ingestion of vitamin D
a) Prolonged bed rest The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.
The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? a) Respiratory acidosis from inadequate ventilation b) Respiratory alkalosis from anxiety and hyperventilation c) Metabolic acidosis from calcium loss due to broken bones d) Metabolic alkalosis from taking analgesics containing base products
a) Respiratory acidosis from inadequate ventilation Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? a) The client who is taking diuretics b) The client with hyperaldosteronism c) The client with Cushing's syndrome d) The client who is taking corticosteroids
a) The client who is taking diuretics
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? a) Twitching b) Hypoactive bowel sounds c) Negative Trousseau's sign d) Hypoactive deep tendon reflexes
a) Twitching The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? a) Weight loss and poor skin turgor b) Lung congestion and increased heart rate c) Decreased hematocrit and increased urine output d) Increased respirations and increased blood pressure
a) Weight loss and poor skin turgor A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.
The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? a) pH 7.25, Paco2 50 mm Hg (50 mm Hg) b) pH 7.35, Paco2 40 mm Hg (40 mm Hg) c) pH 7.50, Paco2 52 mm Hg (52 mm Hg) d) pH 7.52, Paco2 28 mm Hg (28 mm Hg)
a) pH 7.25, Paco2 50 mm Hg (50 mm Hg) Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis, the pH is decreased and the Paco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.
A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. a) Broth b) Coffee c) Gelatin d) Pudding e) Vegetable juice f)Pureed vegetables
a, b, c a) Broth b) Coffee c) Gelatin A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.
The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply. a) Ensure adequate oxygenation. b) Provide assistance to prevent falls. c) Monitor medication administration of diuretics. d) Monitor for numbness and tingling around the mouth. e) Prevent complications during potassium administration.
a, b, c ,e a) Ensure adequate oxygenation. b) Provide assistance to prevent falls. c) Monitor medication administration of diuretics. e) Prevent complications during potassium administration. The priorities for nursing care of a client with hypokalemia are ensuring adequate oxygenation, client safety for fall prevention and potassium administration, and monitoring for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.
The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. a) Peas b) Nuts c) Cheese d) Cauliflower e) Processed oat cereals
a, b, d a) Peas b) Nuts d) Cauliflower The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. a) Nausea b) Confusion c)Bradypnea d) Tachycardia e) Hyperkalemia f) Lightheadedness
a, b, d, f a) Nausea b) Confusion d) Tachycardia f) Lightheadedness Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.
The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. a) U waves b) Absent P waves c) Inverted T waves d) Depressed ST segment e) Widened QRS complex
a, c, d a) U waves c) Inverted T waves d) Depressed ST segment The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.
The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? a) An oral temperature of 98.8°F (37.1°C) b) A urine specific gravity of 1.043 c) A urine output that is pale yellow d) A blood pressure of 120/80 mm Hg
b) A urine specific gravity of 1.043 The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.005 to 1.030. A temperature of 98.8°F (37.1°C) is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range. SPECIFIC GRAVITY FOR KIDS: 1.002- 1.020 (?)
A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? a) Weighs athletes before, during, and after football practice b) Asks the athletes to take a salt tablet before football practice c) Schedules fluid breaks every 30 minutes throughout practice d) Tells the athletes to drink 16 oz (475 mL) of fluid per pound lost during practice
b) Asks the athletes to take a salt tablet before football practice Salt tablets should not be taken because they can contribute to dehydration. Frequent fluid breaks should be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent dehydration, 16 oz (475 mL) of fluid should be consumed for every pound lost.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis
b) Metabolic alkalosis Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.
A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? a) Confusion b) Muscle weakness c) Mental status changes d) Depressed deep tendon reflexes
b) Muscle weakness Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? a) Sustained tissue damage b) Requires nasogastric suction c) Has a history of Addison's disease d) Uric acid level of 9.4 mg/dL (559 mmol/L)
b) Requires nasogastric suction The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia.
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? a) Metabolic acidosis, compensated b) Respiratory alkalosis, compensated c) Metabolic alkalosis, uncompensated d) Respiratory acidosis, uncompensated
b) Respiratory alkalosis, compensated The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. a) Peas b) Raisins c) Potatoes d) Cantaloupe e) Cauliflower f) Strawberries
b, c, d, f b) Raisins c) Potatoes d) Cantaloupe f) Strawberries The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.
A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. What foods should the nurse tell the mother are acceptable to consume while breast-feeding? Select all that apply. a) 1% milk b) Egg yolk c) Dried beans d) Hard cheeses e) Green leafy vegetables
b, c, e b) Egg yolk c) Dried beans e) Green leafy vegetables Breast-feeding mothers with lactose-intolerant infants need to be encouraged to limit dairy products. Milk and cheese are dairy products. Alternative calcium sources that can be consumed by the mother include egg yolk, dried beans, green leafy vegetables, cauliflower, and molasses.
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. a) Respirations that are shallow b) Respirations that are increased in rate c) Respirations that are abnormally slow d) Respirations that are abnormally deep e) Respirations that cease for several seconds
b, d b) Respirations that are increased in rate d) Respirations that are abnormally deep Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.
The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? a) Bradycardia b) Elevated blood pressure c) Changes in mental status d) Bilateral crackles in the lungs
c) Changes in mental status A client with dehydration is likely to be lethargic or complain of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? a) Muscle twitches b) Decreased urinary output c) Hyperactive bowel sounds d) Increased specific gravity of the urine
c) Hyperactive bowel sounds The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.
The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? a) Urinary output b) Wound drainage c) Integumentary output d) The gastrointestinal tract
c) Integumentary output Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.
The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis
c) Respiratory acidosis The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.
The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply. a) Oranges b) Broccoli c) Margarine d) Cream cheese e) Luncheon meats f) Broiled haddock
c, d, e c) Margarine d) Cream cheese e) Luncheon meats Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Margarine, cream cheese, and luncheon meats are high-fat foods.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? a) A decreased pH and an increased PaCO2 b) An increased pH and a decreased PaCO2 c) A decreased pH and a decreased HCO3- d) An increased pH and an increased HCO3-
d) An increased pH and an increased HCO3- Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.
The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? a) Tetany b) Twitches c) Positive Trousseau sign d) Loss of deep tendon reflexes
d) Loss of deep tendon reflexes The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau sign are seen in a client with hypomagnesemia.
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? a) Metabolic acidosis with compensation b) Respiratory acidosis with compensation c) Metabolic acidosis without compensation d) Respiratory acidosis without compensation
d) Respiratory acidosis without compensation The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm). In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3-) level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.
The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation? a) Tap water b) Sterile water c) Distilled water d) Sodium chloride
d) Sodium chloride A potassium level of 4.5 mEq/L (4.5 mmol/L) is within normal range. A sodium level of 132 mEq/L (132 mmol/L) is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) rather than water should be used for gastrointestinal irrigations because it is an isotonic solution.
The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? a) The client has acidotic blood. b) The client is probably overreacting. c) The client is fluid volume overloaded. d) The client is probably hyperventilating.
d) The client is probably hyperventilating. The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an insufficient analysis. No conclusion can be made about a client's fluid volume status from the information provided.
Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? a) The client with colitis b) The client with Cushing's syndrome c) The client who has been overusing laxatives d) The client who has sustained a traumatic burn
d) The client who has sustained a traumatic burn The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.
On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? a) The client taking diuretics and has tenting of the skin b) The client with an ileostomy from a recent abdominal surgery c) The client who requires intermittent gastrointestinal suctioning d) The client with kidney disease and a 12-year history of diabetes mellitus
d) The client with kidney disease and a 12-year history of diabetes mellitus A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.
The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? a) Urine pH of 6 b) Urine that is pale yellow c) Urine output of 40 mL/hr d) Urine specific gravity of 1.032
d) Urine specific gravity of 1.032 The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.
The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. a) U waves b) Widened T wave c) Prominent U wave d) Prolonged QT interval e) Prolonged ST segment
d, e d) Prolonged QT interval e) Prolonged ST segment The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.
