Chapter 18

The pt has been placed on a low-sodium diet to assist in the treatment of hypertension. Which pt statement indicates an understanding of the diet teaching?

"I use a lot of fresh vegetables, although I should give up table salt."

Intravenous Therapy

- Overall goal of fluid IV administration is to correct or prevent fluid and electrolyte imbalances - Intravenous therapy/venipuncture

Fluid (Water)

- Percentage of body weight that is water depends on several factors Age - Premature infant: 90% - Newborn: 70-80% - Twelve years to adult: 50-60% - Older adults: 45-55%

The nurse is reading the primary health care providers progress notes in the client's record and sees the that the PHCP has documented "insensible fluid loss of approx. 800 ml daily?

The client with a fast respiratory rate

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit?

The client with ileostomy

A nurse is reviewing the electronic medical record of a client who has an electrolyte imbalance to the associated risk factor.

A. Hypernatremia- Diabetes Insipidus B.Hypnonatremia- Excessive water intake C. Hypocalcemia- Hypoparathyroidism D. Hypercalcemia- Hyperparathyroidism

The pt is experiencing hyperkalemia. What treatment does the nurse anticipate?

Administration of loop diuretics

The nurse who is caring for a client with renal failure notes. that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional S/S would the nurse expect to note in this client?

An increase in blood pressure

Calcium

- Normal Ionized Calcium blood level is 4.5-5.6 mEq/L. - Hypercalcemia is when calcium levels are over 5.8 mEq/L Immobilized patients tend to lose calcium from their bones and it enters the circulation and causes high blood levels. - Renal Calculi ( kidney stones) can develop in these cases of high levels of calcium

Magnesium

- Normal Magnesium blood level is 1.5-2.5 mEq/L.

Potassium

- Normal Potassium blood level is 3.5-5.0 mEq/L. - Hypokalemia- can cause cardiac complications - Apricots and asparagus have high potassium content

Infiltration

- IV solution seeps into the tissues outside the vein

Intake and Output

- The normal daily loss of fluids must be equaled by the normal daily intake - Recommended daily water intake and output is approximately 2500 mL - Fluid leaves the body through the kidneys, lungs, skin, and GI tract - Water loss is replenished by ingestion of liquids and foods and by metabolism of food and body tissues - The kidneys play an extremely important role in fluid balance. Kidneys must make at least 30 mL/h of urine to eliminate waste products - Dehydration becomes lethal when a patient loses 20% of their body fluid - A way to determine water balance is to weigh the patient the same time each day with the same scale and same clothing type.

Movement of Fluid and Electrolytes

- To carry out their function, substances must enter the cell in the intracellular compartment - Several methods are used by the body to move fluids, electrolytes and other solutes, or dissolved substances into and out of cells -Passive transport processes- This is the method by which inhaled oxygen is moved into the intravascular compartment. A patient inhales oxygen into the lungs, with the oxygen passing by diffusion into the intravascular compartment Diffusion Osmosis- movement of water from an area lo lower concentration to an area of higher concentration. Lasix reduces edema by drawing water from the interstitial space into the intravascular space. Filtration - Active transport processes- this is how electrolytes are moved or transported by hydrostatic pressure. This is a type of active transport where electrolytes are moved from an area of higher concentration to an area of lower concentration.

Respiratory acidosis

- Too much CO2 is retained so pH drops. Body tries to get rid of the extra CO2 to raise the pH by increasing respirations. RR increases, HR increases, patient is lethargic, confused, dizzy

Initiating a blood transfusion

-Type and cross-match is done first. Vital signs completed before and during infusion. Reactions may happen within the first 15 minutes of transfusion. Always hang a bag of IV normal saline up and connected to a Y IV tubing set.

Which pt has the greatest risk for dehydration?

72-year old obese male with a fever and anorexia

A nurse is teaching a class about electrolyte imbalances. Match the electrolyte imbalance to the clinical manifestation.

A Hypocalcemia- Tingling around mouth B. Hypomagnesmia- Hypertension C. Hypernatremia -Dry swollen tongue D. Hyperkalemia- Muscle weakness

The nurse is assessing an older adult and observes dry mucous membranes, increased heart rate, decreased blood pressure, poor skin turgor. The pt seems mildly confused and continuously asks for water. What would the nurse do first?

Assess the pt for additional signs of dehydration.

The nurse receives notification from the laboratory that a pt's potassium level is 6 mEq/L . The nurse has paged the HCP and is awaiting a call back. What would the nurse do first?

Attach the pt to a cardiac monitor

The nurse is monitoring an older pt who is receiving a fluid bolus for dehydration. The nurse notices that the pt suddenly has a slight cough and seems a little short of breath. The pt reports, "I'm okay." What would the nurse do first?

Auscultate the lungs and assess for fluid overload.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which item is likely to contain calcium?

Butter

The nurse us caring for a client with hyperparathyroidism and notes that the client's serum calcium is 13 mg/ dL. Which prescribed medication would the nurse plan to assist in administering to the client?

Calcitonin

The nurse is caring for a pt who had surgery on the parathyroid glands. Which electrolyte level in the low-normal range is the greatest concern?

Calcium

The nurse is checking the laboratory data of a woman who is at risk for osteoporosis. Which electrolyte value is most relevant to this condition?

Calcium level

The pt is on mechanical ventilation. The ABG results indicate that the pt has respiratory alkalosis. What would the nurse do first?

Check the ventilator settings and compare to the orders.

A client has a the following laboratory values: a pH of 7.55, and HCO3 level of 22 mEq/L, and a Pco2 of 30 mm Hg. Which action would the nurse plan to take?

Encourage the client to slow down breathing

A pt with diabetes reports nausea and headache and he appears lethargic. The nurse observes that he is breathing very deeply and rapidly. Based on the assessment findings and the laboratory results, what does the nurse suspect? pH: 7.30 Paco2 : 30 mm Hg ( 4 kPa) Pao2: 70 mm Hg (9.33 kPa) O2 saturation: 98 % HCO3: 18 mEq (18 mmol/L) K+: 6.5 mEq/L (6.5 mmol/ L)

Metabolic acidosis

The nurse is caring for a client with a severe diarrhea. The nurse monitors the client for developing which acid-base disorder?

Metabolic acidosis

A child has gotten into the medicine cabinet in the home and ingested the remaining contents of an aspirin bottle. Which acid-base imbalances does the nurse expect to observe as a result of excessive aspirin ingestion?

Metabolic acidosis and respiratory alkalosis

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Metabolic alkalosis

What is the best food source for calcium?

Milk

Chloride

Normal Chloride blood level is 96-106 mEq/L

The pt used excessive antacids, which resulted in a serum sodium level of 150 mEq/L ( 150 mmil/L) Why would the HCP instruct the nurse to give an IV hypotonic solution?

To correct intracellular dehydration

Earlier in the shift a pt with severe diarrhea seemed irritable, anxious, and twitchy. The RN calls from the pt's room and asks that a vial of calcium gluconate be brought to the room immediately. In addition, to the calcium gluconate, which emergency equipment would LPN try to quickly obtain for pt with a very low calcium?

Tracheotomy tray and a resuscitation bag

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/ L. The nurse understands that a potassium value at this level would be noted with which condition?

Traumatic brain

A client is scheduled for blood to be drawn from the radial artery for an ABG determination. The nurse assists with performing an Allen's test before drawing the blood to determine the adequacy of which?

Ulnar circulation

The nurse sees that the pt is scheduled to a potassium supplement. Inaddition to the last potassium level, what would the nurse assess before administering the potassium?

Urinary output

What is the best way for the nurse to determine the pt's fluid balance?

Weigh the pt daily

Metabolic alkalosis

blood pH will be above 7.45 often caused by vomiting gastric contents, taking too many antacids,

The RN reviews the results of the ABG values with the LPN and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to note which on the laboratory report?

pH 7.25, Pco2 50 mm Hg

The pt has COPD for a number of years. Which set of ABG values indicates that the pt is in respiratory acidosis?

pH 7.30, Paco2 50, O2 saturation 93%

The pt has had continuous gastric suction. The nurse recognizes that acid-base imbalances can occur with this treatment. Which laboratory data confirms metabolic alkalosis?

pH elevated, Paco2 normal, and HCO3 - elevated

Alkaline

pH of greater than 7.45 is alkaline

Acidic

pH of less than 7.35 is acid

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which s/s would be an indication of this electrolyte Imbalance?

Generalized muscle weakness

While in the delivery room with his wife, the father-to-be begins to develop an anxiety reaction and lightheadedness. Which intervention does the nurse use to prevent respiratory alkalosis?

Have him breath into a paper bag

A nurse is teaching a class about fluid imbalances. Sort the following manifestations into either hypovolemia or hypervolemia.

Hypervolemia - Breath sounds with crackles - Weight gain - Decreased urine specific gravitty Hypovolemia - Flat neck veins - Sunken eyeballs

A nurse on a med-surge unit is caring for a group of clients. Sort the following clients to those at risk for hypovolemia or those at risk for hypervolemia.

Hypovolemia - A client who has nasogastric suctioning - A client who is taking diuretics Hypervolemia - A client who has syndrome of inappropriate antidiuretic hormone - A client who has cirrhosis

The pt has experienced a prolonged episode of diarrhea. Which clinical observation is consistent with the development of metabolic acidosis?

Increased RR

The RN initiates a blood transfusion and then the LPN is assigned to monitor pt. An hour after the transfusion is started, the pt reports nausea. " not feeling right" and demonstrates wheezing. What would the LPN do first?

Stop the transfusion and keep the vein open with normal saline

The nurse is supervising a nursing student who is inserting an IV catheter. Which actions prompts the supervising nurse to intervene?

Students looks for vein in forearm distal to a dialysis shunt

Which pt has the greatest risk for developing hypokalemia?

Takes prescribed loop diuretic

Acid-Base Balance

- Acid-base balance means homeostasis of the hydrogen ion concentration in the body fluids -The ratio needed for homeostasis is 1 part carbonic acid to 20 parts bicarbonate ( 1:20) Physiologic buffers- order of effectiveness: - Blood buffers ( Bicarbonate/carbonic acid system) Lungs Kidneys - These 3 buffers keep the pH in a normal range. They work constantly to maintain a normal pH

The nurse is reviewing the medical record of the client. The nurse should identify which of the following findings is a risk factor for the development of hypocalcemia? Select all that apply

- Bariatric surgery -Diarrhea - Thyroid cancer

Septicemia

- Blood infection from poor technique in IV insertion or use of contaminated equipment

Metabolic acidosis

- Blood pH will be below 7.35 and the oxygen readings are within normal limits. Can happen from DKA, hyperventilation, shock, starvation, renal failure, dehydration. Get these people to do deep breathing exercises to help get rid of some CO2 to raise their pH to reduce acidity

Respiratory alkalosis

- Caused by hyperventilation as the lungs blow off large amounts of CO2. symptoms are tetany and muscle weakness, tachypnea, and cardiac arrhythmia

the nurse offers to take an older neighbor to the grocery store. As they are shopping, the neighbor tell the nurse that, "My doctor told me to watch my salt intake." Which items in the shopping cart would the nurse suggest they put back on the shelf? Select all that apply

- Cheddar cheese - Ketchup - Pretzels - Frozen Tv dinner

Which clients would the nurse determine to be at risk for development of metabolic alkalosis? Select all that apply

- Clients admitted with aspirin overdose - Client receiving oral furosemide 40 mg daily

The pt needs to have accurate intake and output recorded for every shift. Which sensible fluid losses must be included in the output? Select all that apply

- Diarrhea stools -Hemovac drainage - Contents from an ileostomy bag - Secretions from nasogastric suction - Drainage for indwelling urinary catheter bag

Electrolytes

- Electrolytes are measured by weight and their chemical activity is expressed in milliequivalents. - 1 mEq of any electrolyte is equal to 1 mEq of hydrogen

A nurse is performing an assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? Select all that apply

- Hyperthermia - Orthostatic hypotension - Decreased skin turgor

The nurse is reviewing the data on the client who has hypovolemia. The nurse should identify which of the following findings is a manifestation of hypovolemia?

- Increase hematocrit (hct) - Decreased urine output - Increased sodium level

Phlebitis

- Inflammation of the vein

Thirst Mechanism

- Main regulator of fluid intake - Osmoreceptors in the hypothalamus stimulate the sensation of thirst - Anyone unable to respond or perceive thirst mechanism is at increased risk for dehydration

What purposes do the electrolytes serve in the body? Select all that apply

- Maintenance of normal body metabolism - Regulation of Water balance in the body - Regulation of water and electrolytes contents within cells - Formation of hydrochloric acid in gastric juice

Bicarbonate

- Normal Bicarbonate blood level is 22-24 mEq/L

Sodium

- Normal Sodium blood level is 135-145 mEq/L - The most abundant electrolyte in the body. - Sodium is the major electrolyte in the extracellular fluid. - Hypernatremia is when there is a greater than normal concentration of sodium which leads to retained fluids and edema

Autologous blood transfusion

- Patient donates their own blood ahead of time then is infused their own blood if needed after surgery.

The nurse is caring for a client with respiratory insufficiency. The ABG results indicate a pH of 7.50 and a Pco2 of 30 mm Hg and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value would the nurse expect to note?

A potassium level of 3.0

The nurse meets resistance while attempting to flush an intermittent saline lock with 10 ml of saline. Which action would the nurse take first?

Assess for kinks or clamped tubing.

The nurse notes that a resident who lives in a Long- term care center has poor fluid intake and spends most of the day dozing in a chair. Based on this observation, which subjective report is the resident most likely to report?

Constipation

The pt has an IV infusion of normal saline. The pt reports mild discomfort at the insertion site and the nurse observes the skin is pale and edematous, feels cool to the touch, and the flow rate is sluggish. What would the nurse do first?

Discontinue the IV

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding will the nurse expect to note as a result of this Long-term use?

Increased specific gravity of urine

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dl. Based on this laboratory value, the nurse would take which action?

Inform the registered nurse of laboratory value.

Fluid Compartments

Intracellular fluid - Fluid inside the billions of cells within the body Extracellular fluid - Interstitial fluid - Intravascular fluid - The fluids in the interstitial and intravascular compartments are combined to form the extracellular compartment.

The nurse is caring for a postoperative pt. Which solution is the HCP most likely to prescribe to replace the fluid deficiency r/t the pt's NPO status is the pre- and postoperative period?

Isotonic solution

The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How would the nurse correctly document this observation in the medical record?

Kussmaul's respirations

Following thyroid surgery, the pt reports nausea and a tingling sensation around nose, mouth, ears, fingers, and toes. The nurse observe muscle spasms in the pt's feet and hands. What is the most important S/S for the nurse to observe for and report?

Respiratory distress

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. What would the nurse look for on the cardiac monitor as a result of this laboratory value?

Narrow, peaked T waves

The nurse is supervising a new nurse who will administer IV potassium to a pt. When would the supervising nurse intervene?

New nurse dose with a sterile needle and syringe and scrubs the IV insertion port

The nurse hears in report that the pt has been receiving Aluminum hydroxide to correct an electrolyte imbalance. Which electrolyte level would the nurse check to evaluate the efficacy of the medication?

Phosphorous level

The pt is encouraged by his doctor to eat foods that is rich in potassium. Which lunch tray would be the best?

Pork cutlet with milk gravy and mushrooms and melon salad

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which s/s could the nurse expect to note in this client hyponatremia is present?

Postural blood pressure changes

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/ dl. The nurse understands that which conditions would cause this serum calcium level?

Prolonged bed rest

The pt has medical diagnosis of diabetic ketoacidosis. Which clinical manifestation indicates that the blood buffer system is exhausted?

RR is increased

The nurse is caring for a client with a diagnosis of COPD. The nurse would monitor the client for which acid-base imbalance ?

Respiratory acidosis

The nurse is told that ABG results indicate a pH of 7.50 and a Pco2 of 32 mm Hg. The nurse determines that these results are indicative of which acid-base balance?

Respiratory alkalosis

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at the least likely risk for the development of third-spacing?

The client with diabetes mellitus

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which conditions

The client with syndrome of innapropriate secretion of antidiuretic hormone.