Chapter 4: Fluid and Electrolyte and Acid-Base Imbalances ~ Nursing 1 Medical Surgical Nursing

A patient with a diagnosis of thyroid cancer is postoperative day 1 following a total thyroidectomy in which her parathyroid gland was also removed. When assessing for related electrolyte imbalances, what question should the nurse ask the patient?

"Are you feeling any tingling in your hands or around your mouth?". When the parathyroid gland is removed, this can cause tetany.

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:

155 mEq/L (155 mmol/L)

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement?

Administer small volumes of a hypertonic solution.

A volume-depleted patient would present with which of the following diagnostic lab results?

BUN-to-creatinine ratio of 24:1

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?

Bicarbonate

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply.

Distended neck veins. Crackles in lungs. Shortness of breath.

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.

Document presenting signs and symptoms. Compare ABG findings with previous results. Maintain intake and output records.

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?

Presence of Trousseau sign Radical neck dissection is caused by hypocalcemia.

A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant?

Provide oral care every 2-3 hours

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?

Pulse

Early signs of hypervolemia include:

Increased breathing effort and weight gain.

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely?

Magnesium

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

muscle weakness.

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48

A client's potassium level is moderately elevated. The nurse is reviewing the ECG tracing. Identify the area on the tracing where the nurse would expect to see a peak.

.....

A client diagnosed with hypernatremia needs fluid volume replacement. What intravenous solution would be the safest for the nurse to administer?

0.45% sodium chloride. A hypotonic solution (half-strength saline) is the solution of choice and considered safer than 5% dextrose in water because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema.

Which electrolyte is a major anion in body fluid?

Chloride. Anion = chloride Cation = sodium, potassium, calcium.

A client with emphysema is at a greater risk for developing which acid-base imbalance?

Chronic respiratory acidosis.

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Confusion and seizures

An adult client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next?

Consider sodium restriction with discontinuation of salt tablets.

The nurse assesses a client who is diagnosed with bulimia nervosa and at risk for alterations in both fluid and electrolyte balance.

During the assessment, the nurse focuses on monitoring the client for hypokalemia as evidenced by cardiac arrhythmia.

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

Elevated blood pressure

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?

Elevated hematocrit level

A client with mild fluid volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this client?

Hydrochlorothiazide Thiazide diuretics are for mild to moderate HYPERvolemia. Loop diuretics are also for HYPERvolemia. Thiazide diuretics blocks sodium from being reabsorbed in the distal tube. 5-10% of sodium is reabsorbed. Loop diuretics can cause sodium and water to be lost because they block sodium from being reabsorbed in the loop of Henle (in the ascending direction). 20-30% of filtered sodium is reabsorbed.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?

Jugular vein distention is a sign of vascular fluid overload.

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?

Metabolic acidosis

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?

Metabolic alkalosis

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions?

Neurological system

A 43-year-old patient with a history of alcohol abuse has been admitted to an acute medical unit with complications resulting from liver failure. Upon assessment, the patient's abdomen is distended, firm to touch, and nontender. The nurse recognizes that the patient has excess fluid in his peritoneal space (ascites), a problem that results from the disruption of normal movement of water and electrolytes. What process is primarily responsible for maintaining fluid balance along a concentration gradient?

Osmosis

Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

Osmosis

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

Restricting fluids to 800 ml/day.v

A patient with a history of poorly controlled type 1 diabetes has begun displaying the characteristic signs and symptoms of diabetic nephropathy. The patient's nurse recognizes that the patient is at risk of disruptions to fluid balance. What role do the kidneys play in the maintenance of normal fluid balance?

Selectively retaining needed substances and excreting waste products.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

Serum sodium level of 124 mEq/L.

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators?

Sodium level of 150 mEq/L. Hypernatremia (normal serum sodium is 135 to 145 mEq/L).

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH?

The lungs are not able to blow off carbon dioxide.

A nurse is monitoring a client being evaluated who has a potassium level of 7 mEq/L (mmol/L). Which electrocardiogram changes will the client display?

peaked T waves

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction?

"I will not salt my food; instead I'll use salt substitute." Salt substitues contain potassium. Potassium is also found in: fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa, butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, honey, and cola sodas.

The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte imbalance?

Hypocalcemia

When the postcardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which electrolyte imbalance?

Hypermagnesemia

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?

Extracellular fluid deficit. The patient is losing large amounts of fluid. This is also known as a hemorrhage.

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

Muscle weakness

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?

Potassium

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators?

Sodium level of 150 mEq/L

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?

Weight

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

Extreme anxiety Extreme anxiety causes hyperventilation which causes respiratory alkalosis. Carbon dioxide is lost when this occurs.

Which nerve is implicated in the Chvostek's sign?

Facial Chvostek's sign consists of twitching of muscles supplied by the facial nerve when the nerve is tapped about 2 cm anterior to the earlobe, just below the zygomatic arch.

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Increases arterial pH

An elderly patient has developed Clostridium difficile-related diarrhea and been subsequently diagnosed with fluid volume deficit (FVD). The nurse providing care for this patient should anticipate:

The administration of hypotonic or isotonic IV solution.

When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up?

Irregular heart rate. Because potassium, magnesium, and calcium imbalances can cause dysrhythmias

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringer's solution

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

Respiratory acidosis

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

Serum sodium level of 124 mEq/L the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?

Third-spacing. Fluid moves from intravascular --> intracellular --> tissues.

A client weighing 160.2 pounds (72.7 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss?

158.0 lbs (71.7 kg). The patient lost 2.2 lbs. 1lb = 500mL

A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client?

165 mEq/L Normal sodium level: 135- 145 mEq/L Hypernatremia: serum sodium level exceeds 145 mEq/L (145 mmol/L) and the serum osmolality exceeds 300 mOsm/kg. The urine specific gravity and urine osmolality are increased as the kidneys attempt to conserve water (provided the water loss is from a route other than the kidneys).

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be?

275-300 mOsm/kg Normal serum osmolality is 270 to 300 mOsm/kg!

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

7.50 pH

Which of the following measurable urine outputs indicates the client is maintaining adequate fluid intake and balance?

A patient with a minimal urine output of 30 mL/hour

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?

Cerebral edema

You are working on a burn unit. One of your patients is exhibiting signs and symptoms of third spacing, which occurs when fluid moves out of the intravascular space but not into the intracellular space. Based upon this fluid shift, what would the nurse expect the patient to demonstrate?

Hypovolemia

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?

Metabolic alkalosis

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?

Pulse High serum potassium levels can cause cardiac arrhythmia.

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant?

Serum potassium level of 3 mEq/L.

An elderly patient has developed Clostridium difficile-related diarrhea and been subsequently diagnosed with fluid volume deficit (FVD). The nurse providing care for this patient should anticipate:

The administration of hypotonic or isotonic IV solution

A client being treated for a chronic illness has a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which assessment findings will the nurse expect to assess in the client? Select all that apply.

When you have low potassium, you will have: Muscle weakness Abdominal distention Anorexia. Normal serum potassium level: 3.5 to 5 mEq/L