Adult Health: Fluids, Electrolytes & Acid-Base Balance

A. Decreased skin turgor B. Concentrated urine D. Low-grade fever E. Tachypnea Skin turgor is decreased due to lack of fluid within the body and results in dryness of the skin. Urine is concentrated due to lack of fluid in the vascular system, causing a decreased profusion of kidneys and resulting in an increased urine specific gravity. Low-grade fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within in the body. Tachypnea or increased respirations are the body's way to obtain oxygen due to the lack of fluid volume in the body. Bradycardia is wrong because Tachycardia is a manifestation present with fluid volume deficits due to an attempt to maintain normal blood pressure.

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure is 102/64 mm Hg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit (hypovolemia)? Select all that apply A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea

D. tachycardia Tachycardia is an attempt to maintain blood pressure, therefore it is a manifestation of fluid volume deficit (hypovolemia). Moist skin, distended neck veins, and increased urinary output are all manifestations of fluid volume excess (hypervolemia).

A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse expect? A. moist skin B. distended neck veins C. Increased urinary output D. tachycardia

D. Monitor for orthostatic hypotension These are manifestations of dehydration and you would monitor for orthostatic hypotension due to the decreased circulatory volume. You would not limit intake of fluids, look for edema, or encourage the client to ambulate with dehydration. You would encourage fluid, monitor skin turgor, and assist the client out of bed as needed due to them being a fall risk.

A nurse is caring for a client in a long-term care facility who has become weak, confused, and experienced dizziness when standing. The client's temperature is 38.8 C (100.9 F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of the following actions should the nurse take? A. Initiate fluid restrictions to limit intake B. Check for peripheral edema C. Encourage the client to ambulate to promote oxygenation D. Monitor for orthostatic hypotension

A. Depth of respirations A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client's respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status.

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? A. Depth of respirations B. Bowel sounds C. Grip strength D. Electrocardiography

D. Metabolic alkalosis Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis

A nurse is obtaining arterial blood gases for a client who has vomited for 24 hr. The nurse should expect which of the following acid base imbalances to result from vomiting 24 hr? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

C. "Call your primary health care provider for diarrhea." One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia. Cooking methods are not a cause of hyponatremia.

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? A. "Have you spouse watch you for irritability and anxiety." B. "Notify the clinic if you notice muscle twitching." C. "Call your primary health care provider for diarrhea." D. "Bake or grill your meat rather than frying it."

C. I take sodium bicarbonate after every meal to prevent heartburn. Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching? A. I dont drink milk because it gives me gas and diarrhea. B. I have been taking digoxin every day for the last 15 years. C. I take sodium bicarbonate after every meal to prevent heartburn. D. In hot weather, I sweat so much that I drink six glasses of water each day.

B. Dehydration With dehydration, the urine is usually concentrated, with a specific gravity greater than 1.030 and has a dark amber color and strong odor. A urine specific gravity is reflective of dehydration . Overhydration= low urine specific gravity. Renal disease is based on other parameters.

What is the nurse's interpretation of a client's urine specific gravity of 1.039? A. Overhydration B. Dehydration C. Normal value for an adult D. Renal disease

A. Sodium Hyponatremia occurs when serum sodium levels are very high, this condition causes excitable tissues to over respond to stimuli. This leads to irritability and severe cellular dehydration. Hyperkalemia, an excess of calcium, decreases the sensitivity of excitable tissues to normal stimuli. Hyperphosphatemia is, excess phosphorus, causes hypocalcemia. Hyper magnesium access magnesium causes hypertension, bradycardia, central nervous system changes, and neuromuscular changes.

Which electrolyte excess results in cellular irritability and severe cellular dehydration? A. Sodium B. Calcium C. Phosphorus D. Magnesium

A. Bradycardia B. Muscle twitching C. Extremity numbness D. Cardiac dysrhythmias E. Hyperactive bowel sounds What is the potassium level of 6.8 MEQ/L, this patient has hyperkalemia, a condition that causes multiple clinical manifestations including bradycardia, muscle twitching and numbness of the hand and feet, cardiac dysrhythmias, and hyper active bowel sounds.

Which finding would the nurse expect during the assessment of a patient with a serum potassium level of 6.8 MEQ/L? Select all that apply A. Bradycardia B. Muscle twitching C. Extremity numbness D. Cardiac dysrhythmias E. Hyperactive bowel sounds

C. Sodium 149 mEq/L A normal serum sodium ranges between 136 and 145 mEq/L. Hypernatremia is a serum sodium value higher than 145 mEq/L. The other values are within normal range.

Which serum value indicates to the nurse that the client has hypernatremia? A. Potassium 3.9 mEq/L B. Chloride 103 mEq/L C. Sodium 149 mEq/L D. Potassium 4.9 mEq/L

B. Connect the client to a cardiac monitor. This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

15. A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? A. Encourage oral fluid intake. B. Connect the client to a cardiac monitor. C. Assess urinary output. D. Administer oral calcitonin.

A. ECG changes Potassium levels can affect the heart and result in arrhythmias. Constipation, polyuria and paresthesia are all manifestations of hypokalemia.

A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? A. ECG changes B. Constipation C. Polyuria D. Paresthesia

A. Assess clients rate, rhythm, and depth of respiration. Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.

A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? A. Assess clients rate, rhythm, and depth of respiration. B. Measure the clients pulse and blood pressure. C. Document the findings and continue to monitor. D. Notify the physician as soon as possible.

A. Reduced deep tendon reflexes B. Drowsiness C. Increased respiratory rate Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate and depth. A positive Trousseaus sign is associated with alkalosis. Decreased urine output is not a manifestation of metabolic acidosis.

A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply.) A. Reduced deep tendon reflexes B. Drowsiness C. Increased respiratory rate D. Decreased urinary output E. Positive Trousseaus sign

D. Metabolic alkalosis Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

C. A 76 year old who is cognitively impaired. Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration.

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? A. A 36 year old who is prescribed long-term steroid therapy. B. A 55 year old who recently received intravenous fluids. C. A 76 year old who is cognitively impaired. D. An 83 year old with congestive heart failure.

C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? A. Prepare to administer patiromer by mouth. B. Provide a heart-healthy, low-potassium diet. C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. D. Prepare the client for hemodialysis treatment.

A. Calculate pulse pressure with each blood pressure reading. C. Assess for pitting edema in dependent body areas. D. Monitor trends in the client's daily weights. E. Assist the client to change positions frequently. F. Teach client and family how to read food labels for sodium. Appropriate interventions for the client who has overhydration include calculating the pulse pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client's dependent body areas, monitoring trends in the client's daily weight as fluid retention is not always visible, protecting the client's skin by helping him or her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. The nurse assesses skin turgor on the chest or forehead.

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) A. Calculate pulse pressure with each blood pressure reading. B. Assess skin turgor using the back of the client's hand. C. Assess for pitting edema in dependent body areas. D. Monitor trends in the client's daily weights. E. Assist the client to change positions frequently. F. Teach client and family how to read food labels for sodium.

B. Kussmaul respirations The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvosteks sign are manifestations of the electrolyte imbalances that accompany alkalosis.

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess? A. Agitation B. Kussmaul respirations C. Seizures D. Positive Chvostek's sign

E. Dysrhythmia F. Tachypnea Dysrhythmia and tachypnea are expected findings in a client with metabolic acidosis. Tachycardia is an expected finding for a client who has respiratory acidosis or metabolic alkalosis. Hypertension is an expected fining for a client with respiratory acidosis. Hyperreflexia is an expected finding for a client who has metabolic alkalosis.

A nurse is assessing a client who has pancreatitis. The client's atrial blood gases reveal metabolic acidosis. Which of the following are expected findings? Select all that apply A. Tachycardia B. Hypertension C. Bounding pulse D. Hyperreflexia E. Dysrhythmia F. Tachypnea

A. Assess the client's respiratory rate, rhythm, and depth. In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy.

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? A. Assess the client's respiratory rate, rhythm, and depth. B. Measure the client's pulse and blood pressure. C. Document findings and monitor the client. D. Call the health care primary health care provider.

A. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? A. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. B. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. C. A 67 year old who is experiencing pain and is prescribed ibuprofen. D. A 73 year old with tachycardia who is receiving digoxin.

B. Anxious client who has tachypnea. Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss.

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? A. Client taking furosemide. B. Anxious client who has tachypnea. C. Client who is on fluid restrictions. D. Client who is constipated with abdominal pain.

B. Metabolic acidosis- Older adult who is following a carbohydrate-free diet C. Respiratory alkalosis- Client on mechanical ventilation at a rate of 28 breaths/min E. Metabolic alkalosis- Older client prescribed antacids for gastroesophageal reflux disease Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) A. Metabolic alkalosis- Young adult who is prescribed intravenous morphine sulfate for pain B. Metabolic acidosis- Older adult who is following a carbohydrate-free diet C. Respiratory alkalosis- Client on mechanical ventilation at a rate of 28 breaths/min D. Respiratory acidosis- Postoperative client who received 6 units of packed red blood cells E. Metabolic alkalosis- Older client prescribed antacids for gastroesophageal reflux disease

B. Sodium bicarbonate This clients arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate should be replaced to help restore this clients acid-base balance. Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the clients pH, the client has excessive diarrhea and cannot afford to lose more fluid. Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their oxygen saturation at 90%, or who have respirator muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for this client.

A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive? A. Furosemide (Lasix) 40 mg B. Sodium bicarbonate C. Mechanical ventilation D. Indwelling urinary catheter

D. Teach the client fall prevention measures. The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? A. Monitor daily hemoglobin and hematocrit values. B. Administer furosemide (Lasix) intravenously. C. Encourage the client to take deep breaths. D. Teach the client fall prevention measures.

D. Dangle the client on the bedside before ambulating. An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? A. Ask family members to speak quietly to keep the client calm. B. Assess urine color, amount, and specific gravity each day. C. Encourage the client to drink at least 1 L of fluids each shift. D. Dangle the client on the bedside before ambulating.

B. Assess client further for fall risk. Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more thorough evaluation of the client's risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? A. Measure intake and output every 4 hours. B. Assess client further for fall risk. C. Increase the IV flow rate to 250 mL/hr. D. Place the client in a high-Fowler position.

D. Decreased orthostatic changes when standing The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? A. Increased respiratory rate from 12 to 22 breaths/min B. Decreased skin turgor on the client's posterior hand and forehead C. Increased urine specific gravity from 1.012 to 1.030 g/mL

B. Inverted U wave Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression. Elevated ST segment is associated with myocardial infarction. Hypokalemia can cause ST depression. Wide QRS complex can be caused by hyperkalemia. Inverted P waves are associated with junctional rhythms.

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Wide QRS complex B. Inverted U wave C. Inverted P wave D. ST segment elevation

B. "I will weigh myself each morning before I eat or drink." One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won't have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day.

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? A. "I must drink a quart (liter) of water or other liquid each day." B. "I will weigh myself each morning before I eat or drink." C. "I will use a salt substitute when making and eating my meals." D. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

B. "I will eat three well-balanced meals and a snack daily." Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk.

After teaching a client who was malnourished and is being discharged, a nurse assesses the clients understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis? A. "I will drink at least three glasses of milk each day" B. "I will eat three well-balanced meals and a snack daily." C. "I will not take pain medication and antihistamines together." D. "I will avoid salting my food when cooking or during meals."

A. Tall peaked T waves Hyperkalemia has deleterious effects on electrical conduction through the heart and can cause death. Some earlier changes in ECG reflecting rising potassium level include tall, peaked T waves, prolonged PR intervals, flat or absent P waves, and wide QRS complexes.

In reviewing a client's electrocardiogram (ECG), which finding does the nurse associate with hyperkalemia? A. Tall peaked T waves B. Narrow QRS complex C. Tall P waves D. Elevated ST segment

A. Raise the head of the bed to 45˚ Answer: Raise the head of the bed to 45˚. The nurse should raise the head of the bed first to allow for lung expansion and then apply oxygen via 2L N/C. If the client is lying flat, applying O2 first will not help them as much because of the inability to breathe properly. Lying flat on your back makes it difficult to breathe. The nurse can then start an IV, draw labs and start fluids. This client has fluid volume deficit(hypovolemia) from the diarrhea and the nurse should expect metabolic acidosis if an ABG is performed. Remember, if it comes out of the mouth (vomiting) they are losing acid, if it comes out the other end, they are losing base and will become acidotic.

The ED nurse has just received a client from the ambulance service who's family said the client has had diarrhea for the last two days . Vital signs are BP 92/62, HR 107, temp. 99.6˚ F, O2 saturation 93% on room air. What is the priority nursing action? A. Raise the head of the bed to 45˚ B. Start 0.9% NS @ 125mLs/hr C. Start a 20g IV line D. Apply oxygen 2L via N/C

C. Tap lightly on the client's cheek Tap the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of the face. Trousseau's sign you would apply the BP cuff. Placing stethoscope bell over carotid would be a to auscultate the carotid bruit. Lowering the chin to chest is a way to assess ROM of the neck.

The nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? A. Apply blood pressure cuff to client's arm B. Place the stethoscope bell over the client's carotid artery. C. Tap lightly on the client's cheek D. Ask the client to lower their chin to their chest

D. The client who has diarrhea and is febrile Rationale: This client has two risk factors for the development of hypovolemia, or dehydration. Diarrhea can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit (hypovolemia). The client receiving normal saline at 125mL/hr is at risk for hypervolemia. The client who has been NPO since midnight can tolerate this time frame and will most likely have IV fluids running to ensure that they do not become dehydrated. The client with an NG tube does have a risk factor for hypokalemia, but not hypovolemia because it is set at low intermittent suction. Continuous NG suction could put the patient at risk for hypovolemia.

The nurse is caring for four hospitalized clients. Which of the following clients will the nurse identify as being most at risk for hypovolemia? A. The client with normal saline running IV at 125mL/hour B. The client with an NG tube at low wall suction. C. The client who has been NPO since midnight for endoscopy D. The client who has diarrhea and is febrile

C. Abnormally prominent U wave Answer: Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.

The nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG will the nurse interpret as a sign of hypokalemia? A. Elevated ST segment B. Peaked T waves C. Abnormally prominent U wave D. Inverted P Waves

C. Prolonged PR intervals Wayne hyperkalemia's present, and individual may show absent P waves, tall T waves, prolong PR interval's, and wide QRS complexes.

Which ECG finding is consistent with hyper kalemia? A. Absent T waves B. Elevated P waves C. Prolonged PR intervals D. Shortened QRS complexes

C. Cardiovascular The potassium controls conductivity within the heart, so the cardiovascular system of a patient with a serum potassium level of 5.9 Emmy Q/L would be affected. The respiratory and genitourinary systems control acid base balance. The integumentary system controls fluid and some sodium balance through perspiration.

Which body system with a nurse reassess of a patient's laboratory results indicate the serum potassium level of 5.9 MEQ/L? A. Respiratory B. Genitourinary C. Cardiovascular D. Integumentary

C. 72 yr old w/ diabetes mellitus who also takes a diuretic daily This client has three risk factors for electrolyte imbalance: older adult, endocrine disorder, and takes diuretics (which alters fluid and electrolyte excretion). The 80 year old does have increased risk due to age however he or she didnt have any other specific risk factors listed.

Which client does the nurse remain most alert for an electrolyte imbalance? A. 49 yr old w/ intermittent asthma who also uses albuterol inhaler PRN B. 60 yr old w/ sprained wrist who also takes acetaminophen for pain C. 72 yr old w/ diabetes mellitus who also takes a diuretic daily D. 80 yr old w/ anemia who takes iron supplements

D. Respiratory insufficiency Respiratory changes may occur in patients with hypokalemia because of respiratory muscle weakness resulting in shallow respirations. The respiratory status of a patient with hypokalemia should be assessed at least every two hours before respiratory insufficiency is a major cause of death for these patients. A stroke is not a risk factor for Hypokalemia. Hypokalemia does not cause renal failure, rather, hyperkalemia is caused by renal failure. Dysrhythmias may occur because of hypokalemia, but they are not the major cause of death in patients with Hypokalemia.

Which condition is a major cause of death in patients with hypokalemia? A. Stroke B. Renal failure C. Cardiac arrest D. Respiratory insuffiency

A. Sodium Hyponatremia can cause mental status changes, including lethargy and coma, as well as seizure activity. Low sodium levels can also cause decrease deep tendon reflexes and diarrhea. Low calcium, potassium, and magnesium levels can cause cardiac dysrhythmias.

Which electrolyte deficiency with the nurse expect to find when reviewing laboratory data for a patient who presents with seizure activity, decreased deep tendon reflexes, and diarrhea? A. Sodium B. Calcium C. Potassium D. Magnesium

A.Sodium Hyponatremia can cause mental status changes, including lethargic and coma, as well as seizure activity. Low sodium levels can also cause decreased deep tendon reflexes and diarrhea. Low calcium, potassium, and magnesium levels can cause cardiac dysrhythmias.

Which electrolyte deficiency would the nurse expect to find when reviewing the laboratory data for a patient who presents with seizure activity, decreased deep tendon reflexes, and diarrhea? A.Sodium B. Calcium C. Magnesium D. Potassium

A. Increased bounding pulse B. Jugular venous distention C. Presence of crackle E. Elevated blood pressure Common symptoms and problems associated with fluid overload first appear in the cardiopulmonary systems. These include: increase pulse rate. bounding pulses, elevated blood pressure, decreased pulse pressure, elevated central venous pressure, distended neck veins and hand veins, engorged varicose veins , weight gain, increased respiratory rate, shallow respirations, shortness of breath, and moist crackles on auscultation. Excessive thirst and orthostatic hypotension are associated with dehydration.

Which findings indicate to the nurse that a client may have hypervolemia (fluid overload)? Select all that apply A. Increased bounding pulse B. Jugular venous distention C. Presence of crackle D. Excessive thirst E. Elevated blood pressure F. Orthostatic hypotension

B. Calcium 10.9 mEq/L The nurse should report the patient's calcium level: it is elevated at 10.9 MEQ/L as a normal value range is 9.0 210.5 MAQ/Elle. The normal sodium level is 135 to 145MAQ/L; at 1:38 Emmy Q/L, the patient sodium level is within normal range. A normal potassium level is 3.5 to 5.0 MEQ/L; at 4.5 MEQ/L, the patient's potassium level is within normal range. The normal range for magnesium is 1.5 to 2.5 MEQ/L; at 2.0 EQ/L, the patient's magnesium level is within normal range.

Which lab result value from a client's morning metabolic panel would the nurse report as abnormal? A. Sodium 138 mEq/L B. Calcium 10.9 mEq/L C. Potassium 4.5 mEq/L D. Magnesium 2.0 mEq/L

B. Greater than 5 lb gained in a week or greater than 1 to 2 lb in a 24 hr period. Rapid weight gain is a good and reliable indicator of fluid retention, which would indicate worsening heart failure that requires intervention. Usually only 0.5 lb of weight gain in a day represents true weight gain. Any amount above that is fluid retention.

Which specific discharge instruction will the nurse provide to prevent harm in a client with advanced heart failure who is at a continued risk for fluid volume overload? A. Greater than 3 lb gained in a week or greater than 1 to 2 lb in a 24 hr period. B. Greater than 5 lb gained in a week or greater than 1 to 2 lb in a 24 hr period. C. Greater than 15 lb gained in a month or greater than 5 lb in a week. D. Greater than 20 lb gained in a month or greater than 5 lb in a week.

C. End-stage renal disease Diuretics are a common and effective drug for the fluid overload associated with pulmonary edema, heart failure and ascites. They are only used when kidney function is normal or at least adequate. In end-stage kidney disease is either greatly or even totally impaired.

For which client problem will the nurse question a prescription for a diuretic? A. Pulmonary edema B. Heart failure C. End-stage renal disease D. Ascites

B. Heart failure The patient is experiencing hypernatremia as the patient sodium level is less than 136 MEQ/L. Causes of hyponatremia include heart failure, being NPO, and excessive diaphoresis. Signs of a hypernatremia would be diarrhea, Cushing syndrome, and a fever of unknown origin.

The diagnosis documented in a patient's health record, which condition with the nurse a tribute to the cause of the patient sodium level of 130 MEQ/L? A. diarrhea B. Heart failure C. Cushing syndrome D. Fever unknown origin

A. Dyspnea B. Edema D. Hypertension E. Weakness Dyspnea is due to an excess of fluids within the body and the lungs, and the client is struggling to breathe. Weight gain can be a result of edema. Blood pressure rises as the heart must work harder due to excess fluid. Weakness is due to the excess fluid that is retained, which depletes energy and increases the workload for the body. Bradycardia is incorrect because tachycardia and bounding pulses are manifestations of fluid volume excess (hypervolemia).

A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5lb) in 48 hr. Which of the following manifestations of fluid volume excess (hypervolemia) should the nurse expect? Select all that apply A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness

D. Grilled chicken breast with glazed carrots Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? A. Slices of smoked ham with potato salad B. Bowl of tomato soup with a grilled cheese sandwich C. Salami and cheese on whole-wheat crackers

D. pH 7.50, PcCO2 45, bicarbonate 36, PaO2 95 Alkalosis has a pH above 7.45, which options A (partially compensated respiratory acidosis) and B (metabolic acidosis) incorrect. Metabolic alkalosis has normal carbon dioxide and oxygen levels because breathing is not affected. Elevated bicarbonate levels (or acid loss) cause metabolic alkalosis.

Which client ABG results would the nurse interpret as metabolic alkalosis? A. pH 7.30, PcCO2 66, bicarbonate 38, PaO2 70 B. pH 7.38, PcCO2 36, bicarbonate 15, PaO2 95 C. pH 7.48, PcCO2 24, bicarbonate 20, PaO2 95 D. pH 7.50, PcCO2 45, bicarbonate 36, PaO2 95

A. Sodium 129 mEq/L A normal serum sodium ranges between 136 and 145 mEq/L. Hyponatremia is a serum sodium value lower than 136 mEq/L. The other values are within normal range.

Which serum value indicates to the nurse that the client has hyponatremia? A. Sodium 129 mEq/L B. Chloride 98 mEq/L C. Sodium 144 mEq/L D. Chloride 103 mEq/L

A. Continuous GI suctioning Continuous gastric suctioning removes fluid before it is absorbed into the body, which decreases fluid intake by the oral route. The ongoing fluid loss, if not measured as replaced by another route, can result in a fluid volume deficit.

With which client condition will the nurse remain most alert for insensible water loss? A. Continuous GI suctioning B. Deep respirations C. Receiving oxygen therapy D. Hypothermia

B. Assess the client's lung sounds every 2 hrs All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client's respiratory status.

The nurse is caring for a client who has a fluid overload. What actions by the nurse takes priority? A. Administer high-ceiling loop diuretics B. Assess the client's lung sounds every 2 hrs C. Place pressure-relieving overlay on the mattress D. Weigh client daily at the same time on the same scale

B. Calcium Low calcium levels can cause muscle spasms, or Charlie horses, in the thigh, calf, or foot while sleeping, sodium loss can result in neurological changes such as seizures. Potassium and magnesium losses can lead to cardiac dysrhythmias.

When a patient reports disturb deep sleep he has a frequent cramping in the Calves. Which electrolyte with the nurse review in the patient's health record? A. Sodium B. Calcium C. Potassium D. Magnesium

A. Increased pulse rate B. Distended neck veins E. Skeletal muscle weakness F. Visual disturbances Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is a normal finding.

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply) A. Increased pulse rate B. Distended neck veins C. Decreased blood pressure D. Warm and pink skin E. Skeletal muscle weakness F. Visual disturbances

C. Respiratory acidosis Answer: Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2),resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45)and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).

The nurse is caring for a client admitted to the emergency department with a respiratory rate of 7 breaths per minute. The arterial blood gas results are as follows: pH 7.22 PaCO2 68 mmHg HCO3 26 mEq/L PaO2 78 mmHg What is the interpretation of this blood gas? A. Metabolic acidosis B. Respiratory alkalosis C. Respiratory acidosis D. Metabolic alkalosis

B. HCO3 = 17 mEq/L Option D is incorrect because the question already states that the client has acidosis and is asking which laboratory value indicates the acidosis is metabolic in origin. The hallmark of a metabolic origin acidosis is a lower than normal bicarbonate level coupled with normal carbon dioxide level and a low pH.

Which laboratory value indicates to the nurse that a client has acidosis as a result of a metabolic problem? A. PaCO2= 43 mm Hg B. HCO3 = 17 mEq/L C. Lactate= 2.5 mmol/L D. pH= 7.32

A. Increased heart rate D. Increased blood pressure E. Increased respiratory rate Increased heart rate is correct. The nurse should expect the client who has fluid volume excess or hypervolemia to have tachycardia and increased cardiac contractility in response to the excess fluid. Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid .Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs. Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume overload to have a decreased hematocrit because of hemodilution. Increase temperature is incorrect. The nurse should expect the client who has fluid volume deficit (Hypovolemia) to have an increase in temperature due to fluid loss.

The nurse is caring for a client who has bounding pulses, crackles in their lungs, and pitting edema. Which additional assessment finding(s) will the nurse expect upon assessment? (Select all that apply.) A. Increased heart rate B. Increased hematocrit C. Increased temperature D. Increased blood pressure E. Increased respiratory rate

A. Sodium polystyrene (kayexelate) Answer: Sodium polystyrene is used for the treatment of hyperkalemia., It removes excess potassium byion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L..

The nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which medication will the nurse administer first? A. Sodium polystyrene (kayexelate) B. Furosemide C. Darbepoetin alfa D. Lactulose

C. Potassium Hyperkalemia, or too much potassium, can cause cardiovascular changes, including peaked T waves and widened QRS complexes. Sodium does not affect the heart rhythm, but it does affect fluid volume. Calcium and balances prolong the ST and QT intervals. Magnesium widen the QRS complex, but it does not cause Peaked T waves.

When an analysis of a patient's Tele Metry strip reveals a widened QRS complex with peaked T waves, which laboratory value with the nurse review before notifying the healthcare provider? A. Sodium B. Calcium C. Potassium D. Magnesium