Chapter 10: Fluid and Electrolytes
A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.) a) Tachypnea b) Tachycardia c) Bradycardia d) Oliguria e) Hypertension
- Oliguria - Tachycardia - Tachypnea Explanation: Hypovolemia, or fluid volume deficit, is indicated by decreased, not increased, blood pressure (hypotension), oliguria, tachycardia (not bradycardia), and tachypnea.
A client admitted with a diagnosis of pancreatitis is found to be malnourished and has begun parenteral nutrition (TPN) as ordered. What lab result will the nurse identify as possibly related to the rate of TPN administration? Select all that apply. a) Phosphorus: 2.3 mg/dL b) Blood glucose 178 mg/dL c) Calcium: 9.2 mg/dL d) Sodium: 140 mEq/L e) Chloride: 99 mEq/L
- Phosphorus: 2.3 mg/dL - Blood glucose 178 mg/dL Explanation: The normal adult range for serum phosphorus is 2.5 to 4.5 mg/dL; normal serum calcium is 8.5 to 10.4 mg/dL; normal sodium level is 135 to 145 mEq/L; normal serum chloride level is 96 to 106 mEq/L; normal blood glucose level for someone without diabetes is 70 to 99 mg/dL. The nurse identifies clients who are at risk for hypophosphatemia and monitors them. Because malnourished clients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Both TPN and PPN are high glucose solutions. For example, a 5% solution is administered for PPN, while a 10% solution is administered for TPN at the same rate, owing to the approximate glucose concentration in the two solutions. All the remaining lab results are within normal limits.
Which solution is hypotonic? a) 0.9% NaCl b) 5% NaCl c) Lactated Ringer solution d) 0.45% NaCl
0.45% NaCl Explanation: Half-strength saline is hypotonic. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A 5% NaCl solution is hypertonic.
The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining? a) 1 L b) 500 ml c) 1250 ml d) 1500 ml
1 L Explanation: A 2-lb weight gain in 24 hours indicates that the client is retaining 1L of fluid.
At which serum sodium concentration might convulsions or coma occur? a) 140 mEq/L (140 mmol/L) b) 145 mEq/L (145 mmol/L) c) 142 mEq/L (142 mmol/L) d) 130 mEq/L (130 mmol/L)
130 mEq/L (130 mmol/L) Explanation: Normal serum concentration level ranges from 135 to 145 mEq/L (135-145 mmol/L). When the level dips below 135 mEq/L (135 mmol/L), hyponatremia occurs. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L (mmol/L) are within the normal range.
The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be a) 135 mEq/L (135 mmol/L) b) 145 mEq/L (145 mmol/L) c) 125 mEq/L (125 mmol/L) d) 155 mEq/L (155 mmol/L)
155 mEq/L (155 mmol/L) Explanation: The client is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium concentration >145 mEq/L (>145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen and dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.
A patient is admitted with severe vomiting for 24 hours as well as weakness and "feeling exhausted." The nurse observes flat T waves and ST-segment depression on the electrocardiogram. Which potassium level does the nurse observe when the laboratory studies are complete? a) 5.5 mEq/L b) 3.5 mEq/L c) 4.5 mEq/L d) 2.5 mEq/L
2.5 mEq/L Explanation: Symptoms of hypokalemia (<3.0 mEq/L) include fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria, decreased bowel motility, ventricular asystole or fibrillation, paresthesias, leg cramps, hypotension, ileus, abdominal distention, and hypoactive reflexes. Electrocardiogram findings associated with hypokalemia include flattened T waves, prominent U waves, ST depression, and prolonged PR interval.
A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? a) >408 mOsm/kg b) 275-300 mOsm/kg c) 350-544 mOsm/kg d) <136 mOsm/kg
275-300 mOsm/kg Explanation: In healthy adults, normal serum osmolality is 270 to 300 mOsm/kg (Crawford & Harris, 2011c).
A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be a) 7.30 b) 7.35 c) 7.45 d) 7.50
7.50 Explanation: The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is >7.45 and the PaCO2 is <38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, gram-negative bacteremia, and inappropriate ventilator settings.
It is important for a nurse to know how to calculate the corrected serum calcium level for a patient when hypocalcemia is seen along with low serum albumin levels. Calculate the corrected serum calcium when the serum calcium is 9 mg/dL and the serum albumin is 3 g/dL. a) 11 mg/dL b) 10.3 mg/dL c) 12 mg/dL d) 9.8 mg/dL
9.8 mg/dL Explanation: To calculate corrected serum calcium, subtract the normal serum albumin level of 4 g/dL from the reported albumin level of 3 g/dL, multiply that value (1) by 0.8 (constant factor) and then add that result (0.8 mg) to the reported serum level of 9 mg/dL. Therefore, 9 + 0.8 = 9.8 mg/dL (corrected value). Note: a constant factor of 0.8 is used because, for every decrease in serum albumin of 1 g/dL below 4 g/dL, the total serum calcium level is underestimated by 0.8 mg/dL.
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? a) A 65-year-old with a myocardial infarction b) A 7-year-old with a fracture tibia c) A 52-year-old with diarrhea d) A 72-year-old with a total knee repair
A 52-year-old with diarrhea Explanation: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution? a) Neutral b) Acidic c) Basic d) Alkaline
Acidic Explanation: Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)? a) Passive diffusion b) Facilitated diffusion c) Active transport d) Osmosis
Active transport Explanation: Active transport requires the use of the body's energy molecule (ATP) to meet body needs for fluid and particle transport. Osmosis is the movement of body fluids through a semipermeable membrane that allows not all substances to pass through. Passive diffusion allows the movement of substances from an area of higher concentration to lower concentration. Facilitated diffusion has certain dissolved substances that require the assistance from a carrier module to pass through the semipermeable membrane.
A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement? a) Administer small volumes of a hypertonic solution. b) Monitor the serum sodium for changes hourly. c) Restrict fluids and salt for 24 hours. d) Correct the sodium deficit rapidly with salt.
Administer small volumes of a hypertonic solution. Explanation: In clients with normal or excess fluid volume, hyponatremia is usually treated effectively by restricting fluid with clients who are not neurologically impaired. When the serum sodium concentration is overcorrected (exceeding 140 mEq/L) too rapidly or in the presence of hypoxia or anoxia, the client can develop neurological symptoms. However, if neurologic symptoms are severe (e.g., seizures, delirium, coma), or if the client has traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. Incorrect use of these fluids is extremely dangerous, because 1 L of 3% sodium chloride solution contains 513 mEq (mmol/L) of sodium and 1 L of 5% sodium chloride solution contains 855 mEq (mmol/L) of sodium. The recommendation for hypertonic saline administration in clients with craniocerebral trauma is between 0.10 to 1.0 mL of 3% saline per kilogram of body weight per hour.
A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement? a) Restrict fluids and salt for 24 hours. b) Administer small volumes of a hypertonic solution. c) Monitor the serum sodium for changes hourly. d) Correct the sodium deficit rapidly with salt.
Administer small volumes of a hypertonic solution. Explanation: In clients with normal or excess fluid volume, hyponatremia is usually treated effectively by restricting fluid with clients who are not neurologically impaired. When the serum sodium concentration is overcorrected (exceeding 140 mEq/L) too rapidly or in the presence of hypoxia or anoxia, the client can develop neurological symptoms. However, if neurologic symptoms are severe (e.g., seizures, delirium, coma), or if the client has traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. Incorrect use of these fluids is extremely dangerous, because 1 L of 3% sodium chloride solution contains 513 mEq (mmol/L) of sodium and 1 L of 5% sodium chloride solution contains 855 mEq (mmol/L) of sodium. The recommendation for hypertonic saline administration in clients with craniocerebral trauma is between 0.10 to 1.0 mL of 3% saline per kilogram of body weight per hour.
Which of the following is the most common cause of symptomatic hypomagnesemia in the United States? a) Alcoholism b) Intestinal resection c) Loss of gastric acid d) Inflammatory bowel disease
Alcoholism Explanation: Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Any disruption in small bowel function, as in intestinal resection or inflammatory bowel disease, can lead to hypomagnesemia.
Which is the most common cause of symptomatic hypomagnesemia? a) Sedentary lifestyle b) Alcoholism c) Burns d) Intravenous drug use
Alcoholism Explanation: Alcoholism is currently the most common cause of symptomatic hypomagnesemia. Intravenous drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia.
A volume-depleted patient would present with which of the following diagnostic lab results? a) Capillary refill time of 3 seconds b) Urine specific gravity of 1.02 c) BUN-to-creatinine ratio of 24:1 d) Urinary output of 1.2 L/24 hours
BUN-to-creatinine ratio of 24:1 Explanation: A BUN-to-serum creatinine concentration ratio greater than 20:1 is indicative of volume depletion. The other results are within normal range.
The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? a) PO2 b) Carbonic acid c) Bicarbonate d) PaO2
Bicarbonate Explanation: Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? a) Slow pulse b) Hypertension c) Jaundice d) Chest pain
Chest pain Explanation: Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? a) Tetany and increased blood urea nitrogen (BUN) levels b) Confusion and seizures c) Sunken eyeballs and spasticity d) Flaccidity and thirst
Confusion and seizures Explanation: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.
The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L) and a fluid volume excess. The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving? a) Increase the rate of the intravenous lactated Ringer solution. b) Change the lactated Ringer solution to 2.5% dextrose. c) Discontinue the intravenous lactated Ringer solution. d) Change the lactated Ringer solution to 3% saline.
Discontinue the intravenous lactated Ringer solution. Explanation: The lactated Ringer intravenous (IV) fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer solution contains more sodium than daily requirements, and excess sodium worsens fluid volume excess. Lactated Ringer solution also contains potassium, which would worsen the hyperkalemia.
The nurse assesses a client who is diagnosed with bulimia nervosa and at risk for alterations in both fluid and electrolyte balance. Complete the following sentence by choosing from the lists of options.
During the assessment, the nurse focuses on monitoring the client for hypokalemia as evidenced by cardiac arrhythmia. Explanation: Fluid and electrolyte imbalances are common for clients who are diagnosed with eating disorders, including bulimia nervosa. The client who vomits as a result of purging behavior when diagnosed with bulimia nervosa is at risk for fluid and electrolyte imbalances, including hypokalemia (i.e., low serum potassium level). The client who experiences low serum potassium levels (i.e., hypokalemia) due to a diagnosed eating disorder must be monitored for cardiac arsrhythmia, a potentially life-threatening consequence of this electrolyte imbalance. The client who is diagnosed with bulimia nervosa is at risk for hypovolemia (e.g., dehydration) and hyponatremia (i.e., low serum sodium level), not hypervolemia or hypernatremia (i.e., elevated serum sodium level). While peripheral edema is a symptom of hypervolemia and extreme thirst is a symptom of hypernatremia, this client is at risk for hypovolemia (e.g., dehydration), which is manifested by dry mucous membranes, and hyponatremia, which is manifested by muscle weakness.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? a) Low heart rate b) Rapid respiration c) Subnormal temperature d) Elevated blood pressure
Elevated blood pressure Explanation: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? a) Altered blood urea nitrogen (BUN) value b) Metabolic alkalosis c) Respiratory acidosis d) Extracellular fluid volume deficit
Extracellular fluid volume deficit Explanation: Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. A cause of this loss is hemorrhage.
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? a) Hypercalcemia b) Hypokalemia c) Hypocalcemia d) Hyperkalemia
Hypercalcemia Explanation: The normal reference range for serum calcium is 8.6 to 10.2 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.
Oral intake is controlled by the thirst center, located in which of the following cerebral areas? a) Thalamus b) Cerebellum c) Brainstem d) Hypothalamus
Hypothalamus Explanation: Oral intake is controlled by the thirst center located in the hypothalamus. The thirst center is not located in the cerebellum, brainstem, or thalamus.
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? a) Similar causes are present in both conditions. b) Hypovolemia contains only low blood volume. c) In dehydration, only extracellular is depleted. d) Both conditions result in abnormal laboratory studies.
In dehydration, only extracellular is depleted. Explanation: In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? a) Offer the client fluids frequently. b) Administer ordered supplemental oxygen. c) Instruct the client to breathe into a paper bag. d) Administer an ordered decongestant.
Instruct the client to breathe into a paper bag. Explanation: The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.
The nurse is caring for a client with an arterial blood pH of 7.48 and bicarbonate level of 29 mEq/L (29 mmol/L). Which treatment will the nurse expect to be prescribed for this client? a) Bronchodilator b) Potassium supplements c) Intravenous 0.9% normal saline d) Oxygen through a rebreather mask
Intravenous 0.9% normal saline Explanation: Treatment of both acute and chronic metabolic alkalosis is aimed at correcting the underlying acid-base disorder. Because volume depletion is commonly present, treatment includes restoring normal fluid volume by administering normal saline. Bronchodilators are used to treat respiratory acidosis. Potassium supplements would be used to treat metabolic acidosis. Oxygen delivered through a rebreather mask would be used to treat respiratory alkalosis.
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? Jugular vein distention Weight loss Tetanic contractions Polyuria
Jugular vein distention Explanation: Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.
With which condition should the nurse expect that a decrease in serum osmolality will occur? a) Influenza b) Hyperglycemia c) Uremia d) Kidney failure
Kidney failure Explanation: Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? a) Limit sodium and water intake. b) Give medications that promote fluid retention. c) Assess for dehydration. d) Teach client behaviors that decrease urination.
Limit sodium and water intake. Explanation: Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? a) Heart and lungs b) Lungs and kidney c) Pancreas and stomach d) Kidney and liver
Lungs and kidney Explanation: The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.
The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? a) Magnesium b) Calcium c) Potassium d) Phosphorus
Magnesium Explanation: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? a) Respiratory acidosis b) Metabolic alkalosis c) Respiratory alkalosis d) Metabolic acidosis
Metabolic acidosis Explanation: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? a) Respiratory acidosis b) Metabolic alkalosis c) Metabolic acidosis d) Respiratory alkalosis
Metabolic acidosis Explanation: This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis
Metabolic alkalosis Explanation: Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma bicarbonate concentration. The most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis
Metabolic alkalosis Explanation: Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.
A priority nursing intervention for a client with hypervolemia involves which of the following? a) Establishing I.V. access with a large-bore catheter. b) Encouraging the client to consume sodium-free fluids. c) Drawing a blood sample for typing and crossmatching. d) Monitoring respiratory status for signs and symptoms of pulmonary complications.
Monitoring respiratory status for signs and symptoms of pulmonary complications. Explanation: Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? a) No, start with the sodium chloride IV. b) Yes, this will correct the sodium deficit. c) Yes, along with the hypotonic IV. d) No, sodium intake should be restricted.
No, sodium intake should be restricted. Explanation: The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.
Which is the preferred route of administration for potassium? a) Subcutaneous b) Oral c) Intramuscular d) IV (intravenous) push
Oral Explanation: When the client cannot ingest sufficient potassium by consuming foods that are high in potassium, administering oral potassium is ideal because oral potassium supplements are absorbed well. Administration by IV is done with extreme caution using an infusion pump, with the patient monitored by continuous ECG. To avoid replacing potassium too quickly, potassium is never administered by IV push or intramuscularly. Potassium is not administered subcutaneously.
The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders? a) Calcium: 10 mg/dL b) Potassium: 5.8 mEq/L c) Sodium: 138 mEq/L d) Magnesium:2 mEq/L
Potassium: 5.8 mEq/L Explanation: Normal potassium level is approximately 3.5 to 5.0 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? a) Prepare for gastric lavage. b) Obtain a urine specimen for drug screening. c) Monitor the client's heart rhythm. d) Prepare to assist with ventilation.
Prepare to assist with ventilation. Explanation: Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? a) Negative Chvostek sign b) Presence of Trousseau sign c) Slurred speech d) Muscle weakness
Presence of Trousseau sign Explanation: After radical neck resection, a client is prone to developing hypocalcemia. Hypocalcemia is defined as a serum value <8.6 mg/dL (<2.15 mmol/L). Signs and symptoms of hypocalcemia include Chvostek sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped; and a positive Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? a) Temperature b) Respirations c) Blood pressure d) Pulse
Pulse Explanation: An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client's pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing respirations and temperature because these aren't affected by the serum potassium level.
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? a) Metabolic alkalosis b) Respiratory acidosis c) Metabolic acidosis d) Respiratory alkalosis
Respiratory alkalosis Explanation: A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.
Which of the following arterial blood gas results would be consistent with metabolic alkalosis? a) Serum bicarbonate of 21 mEq/L b) Serum bicarbonate of 28 mEq/L c) PaCO2 less than 35 mm Hg d) pH 7.26
Serum bicarbonate of 28 mEq/L Explanation: Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? a) Tomato juice, low-fat cottage cheese, and three slices of bacon b) Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad c) A frozen, packaged low-fat dinner with a side salad d) Three ounces of sliced ham, beets, and a salad
Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Explanation: Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.
A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse? a) renin-angiotensin-aldosterone system b) bicarbonate-carbonic acid buffer system c) sodium-potassium pump d) ADH-ANP buffer system
bicarbonate-carbonic acid buffer system
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 137 mEq/L (137 mmol/L) potassium 4.6 mEq/L (4.6 mmol/L) chloride 94 mEq/L (94 mmol/L) calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is of highest concern to the nurse? a) potassium 4.6 mEq/L (4.6 mmol/L) b) sodium 137 mEq/L (137 mmol/L) c) calcium 12.9 mg/dL (3.2 mmol/L) d) chloride 94 mEq/L (94 mmol/L)
calcium 12.9 mg/dL (3.2 mmol/L) Explanation: More than 99% of the body's calcium is found in the skeletal system. Hypercalcemia, or calcium levels exceeding 10.2 mg/dL (2.5 mmol/L), can be a dangerous imbalance. The client presents with anorexia, nausea and vomiting, constipation, abdominal pain, bone pain, and confusion. The listed sodium, potassium, and chloride levels are within normal limits.
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? a) dehydration b) hypervolemia c) hypercalcemia d) hyperkalemia
dehydration Explanation: Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. The most common fluid imbalance in older adults is dehydration. Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from excessive oral intake or rapid IV infusion of fluid. Early signs of hypervolemia are weight gain, elevated BP, and increased breathing effort. Hypercalcemia occurs when the serum calcium level is higher than normal. Some of its signs include tingling in the extremities and the area around the mouth (circumoral paresthesia) and muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the blood. Symptoms include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias.
A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment? a) neuromuscular function b) bowel sounds c) electrocardiogram (ECG) results d) respiratory rate
electrocardiogram (ECG) results Explanation: Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? a) spironolactone b) hydrochlorothiazide c) metolazone d) furosemide
furosemide Explanation: Furosemide is the only loop diuretic choice. Hydrochlorothiazide and metolazone are thiazide diuretics that block sodium reabsorption. Spironolactone is a potassium-sparing diuretic that prevents sodium absorption.
A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values: Sodium 134 mEq/L (134 mmol/L) Potassium 3.2 mEq/L (3.2 mmol/L) Chloride 111 mEq/L (111 mmol/L) Magnesium 1.1 mg/dL (0.45 mmol/L) Calcium 8.4 mg/dL (2.1 mmol/L) What fluid and electrolyte imbalance would the nurse relate to the client's findings? a) hypocalcemia b) hypomagnesemia c) hypokalemia d) hyponatremia
hypomagnesemia Explanation: Magnesium, the second most abundant intracellular cation, plays a role in both carbohydrate and protein metabolism. The most common cause of this imbalance is loss in the gastrointestinal tract. Hypomagnesemia is a value less than 1.3 mg/dL (0.45 mmol/L). Signs and symptoms include muscle weakness, tremors, irregular movements, tetany, vertigo, focal seizures, and positive Chvostek's and Trousseau's signs.
Early signs of hypervolemia include a) thirst. b) increased breathing effort and weight gain. c) a decrease in blood pressure. d) moist breath sounds.
increased breathing effort and weight gain. Explanation: Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.
Clients diagnosed with hypervolemia should avoid sweet or dry food because it a) can lead to weight gain. b) increases the client's desire to consume fluid. c) obstructs water elimination. d) can cause dehydration.
increases the client's desire to consume fluid. Explanation: The management goal in hypervolemia is to reduce fluid volume. For this reason, fluid is rationed and the client is advised to take a limited amount of fluid when thirsty. Sweet or dry food can increase the client's desire to consume fluid. Sweet or dry food does not obstruct water elimination or cause dehydration. Weight regulation is not part of hypervolemia management except to the extent it is achieved on account of fluid reduction.
A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the a) client may be developing hyperaldosteronism. b) client has a history of alcohol abuse. c) client's diet is lacking in calcium-rich food products. d) malignancy is causing the electrolyte imbalance.
malignancy is causing the electrolyte imbalance. Explanation: The client's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium concentration >10.2 mg/dL (>2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia through a variety of mechanisms. The client's calcium level is elevated; there is no indication that the client's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.
A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance? a) respiratory acidosis b) metabolic acidosis c) metabolic alkalosis d) respiratory alkalosis
metabolic alkalosis Explanation: Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The client's regular use of baking soda (sodium bicarbonate) may create a risk for this condition. Metabolic acidosis refers to decreased plasma pH because of increased organic acids (acids other than carbonic acid) or decreased bicarbonate. Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary with expired air.
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: a) diaphoresis. b) muscle weakness. c) tremors. d) constipation.
muscle weakness. Explanation: Muscle weakness; bradycardia; nausea; diarrhea; and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.
