Fluid, Electrolyte, and Acid-Base Imbalances (Lewis Med-Surg CH. 16)

Which fluid shift would the nurse anticipate in the patient with dehydration related to nausea and vomiting?

A) Fluid movement from the interstitial space into the blood vessels - In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

What is the normal pH range of the blood, and what ratio of base to acid does this reflect? a. 7.32 to 7.42; 25 to 2 b. 7.32 to 7.42; 28 to 2 c. 7.35 to 7.45; 20 to 1 d. 7.35 to 7.45; 30 to 1

c. 7.35 to 7.45; 20 to 1.

In a patient with a positive Chvostek's sign, the nurse would expect the IV administration of which medication? a. Calcitonin b. Vitamin D c. Loop diuretics d. Calcium gluconate

d. Calcium gluconate Chvostek's sign is a contraction of facial muscles in response to a tap over the facial nerve. This indicates the neuromuscular irritability of low calcium levels. IV calcium is the treatment used to prevent laryngeal spasms and respiratory arrest. Calcitonin and loop diuretics are treatments for hypercalcemia. Oral vitamin D supplements are part of the treatment for hypocalcemia but not for impending tetany.

Which statement by a patient indicates understanding of nursing instructions about their peripherally implanted catheters (PICC)? Select all that apply. 1) "I will need to watch for signs and symptoms of phlebitis for up to 10 days after the PICC is inserted." 2) "A PICC line is usually only used for access up to six months, but it can be left in longer." 3) "I can safely take my blood pressure in the arm with the PICC as long as the cuff is below the insertion site." 4) "A PICC has fewer side effects than a central venous catheter, such as a lower infection rate and fewer insertion complications." 5) "Because the dressing seals off the insertion site, I may continue to take showers or go swimming at the health club."

A) 1, 2, 4 - Patients need to check for phlebitis for up to 10 days after the PICC is inserted (1). PICC lines are typically used for access for up to six months, and they can be left longer (2). PICC lines have fewer side effects than central venous catheters (4). Blood pressure should not be taken on an arm with a PICC line because inflation of the cuff can lead to the risk of vein damage or thrombosis (3). Although the dressing seals the insertion site, the risk for infection is high and the patient should not keep the site submersed in water (5).

Which factors place the older patient at risk for developing the clinical manifestations of dehydration? Select all that apply. 1) Decreased taste sensation 2) Disorientation and confusion 3) Inability to hold a cup or glass 4) Decrease in thirst mechanisms 5) Fear of stomach bloating and discomfort

A) 2, 3, 4 - Some older adults experience mental changes including confusion and disorientation, which may lead to a decrease in fluid intake (2). In addition, older adults may also have musculoskeletal disabilities, such as stiffness of the hands, which make it difficult for them to hold a cup or glass (3). Older adults may have decreased thirst mechanisms; therefore they may not feel like drinking water even if they are dehydrated and have increased osmolality and serum sodium levels (4). Fear of bloating and decreased taste sensation do not affect intake of fluid (1,5).

When planning the care of a patient with dehydration, which data would the nurse instruct the unlicensed assistive personnel (UAP) to report? 1) 60 mL urine output in 90 minutes 2) 1200 mL urine output in 24 hours 3) 300 mL urine output per 8-hour shift 4) 20 mL urine output for two consecutive hours

A) 20 mL urine output for two consecutive hours - The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for two consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

Which task may a registered nurse (RN) on a general medical-surgical unit delegate to a licensed practical nurse (LPN), as permitted by the state nurse practice act? 1) Administering a saline infusion to a patient with diabetic ketoacidosis 2) Assessing a patient with heart failure who has signs of fluid overload 3) Determining if an IV infusion should be given to a patient with an acid-base imbalance 4) Decreasing the rate of an existing IV infusion for a patient about to be discharged home

A) Decreasing the rate of an existing IV infusion for a patient about to be discharged home - Depending on the state's nurse practice act, an LPN can adjust the IV infusion rate for stable patients. A patient about to be discharged home is considered stable (4). Clients with diabetic ketoacidosis, acid─base imbalance, and fluid overload are not considered stable (1,3,2), so tasks related to IV infusions and fluid status for these patients cannot be delegated to the LPN.

Match the acid-base imbalances with their mechanisms. Acid-Base Imbalance Mechanism a. Increased carbonic acid (H2CO3) 1. Metabolic acidosis b. Decreased carbonic acid (H2CO3) 2. Metabolic alkalosis c. Increased base bicarbonate (HCO3−) 3. Respiratory acidosis d. Decreased base bicarbonate (HCO3−) 4. Respiratory alkalosis

a. Increased carbonic acid (H2CO3) = Respiratory acidosis b. Decreased carbonic acid (H2CO3) = Respiratory alkalosis c. Increased base bicarbonate (HCO3−) = Metabolic alkalosis d. Decreased base bicarbonate (HCO3−) = Metabolic acidosis Respiratory acid-base imbalances are associated with excesses or deficits of carbonic acid. Metabolic acid-base imbalances are associated with excesses or deficits of bicarbonate.

A common collaborative problem related to both hyperkalemia and hypokalemia is which potential complication? a. Seizures b. Paralysis c. Dysrhythmias d. Acute kidney injury

c. Dysrhythmias Potassium maintains normal cardiac rhythm, transmission and conduction of nerve impulses, and contraction of muscles. Cardiac cells have the most clinically significant changes with potassium imbalances because of changes in cardiac conduction. Although paralysis may occur with severe potassium imbalances, cardiac changes are seen earlier and much more commonly.

Which statement would the nurse use in response to a patient's inquiry about why his or her health care provider prescribed a b-type natriuretic peptide (BNP)?

A) "The blood test will let us know if there is excess fluid in the heart." - BNP is a hormone produced when the atrial pressure increases. This blood test is used to diagnose the severity and treatment outcomes of congestive heart failure (CHF). The atrial pressure increases because of increased venous return and hypernatremia. The test gives no information to rule out urine retention or the presence of stomach ulcers. A serum sodium level is needed to determine hyponatremia.

A patient with consistent dietary intake who loses 1 kg of weight in 1 day has lost _________________ mL of fluid.

A) 1000 mL

A man who weighs 90 kg has a total body water content of approximately _________________ L. .

A) 54 to 45 L 90 kg × 60% = 54, 90 kg × 50% = 45

For the patient exhibiting clinical manifestations of hypovolemic shock, which fluid replacement therapy would the nurse prepare to administer when responding to the health care provider's prescription?

A) 0.9% NaCl - Isotonic saline (0.9% NaCl) may be used when a patient has experienced both fluid and sodium losses or as a vascular fluid replacement in hypovolemic shock. The nurse would not administer 0.45% saline, 5% dextrose in 0.45% saline, or dextran, as these are not appropriate for fluid replacement in hypovolemic shock.

When assessing a patient's skin turgor, the nurse pinched a fold of skin over the sternum and released the fold. Return of the skin to the original position required 22 seconds. Which term would the nurse use to document this finding?

A) Poor - Poor skin turgor is characterized by skin that takes 20 to 30 seconds to return to normal after being pinched. "Lagged" is not a term used to describe skin turgor. With normal skin turgor, the skin resumes shape within seconds of being released. "Decreased" skin turgor is too vague a description of the finding.

Priority Decision: A patient just had a CVAD inserted. Number the following nursing actions related to care of the CVAD in the correct order to complete these actions. Number 1 is the first action and number 8 is the last action. a. Perform hand hygiene. b. Flush each line with 10 mL of normal saline. c. Use strict sterile technique to change the dressing. d. Clamp unused lines after flushing if not using positive pressure valve caps. e. Assess the CVAD insertion site for redness, edema, warmth, drainage, and pain. f. Use friction to cleanse the CVAD insertion site with chlorhexidine-based preparation. g. Turn the patient's head to the side away from the CVAD insertion site when changing the caps. h. Obtain chest x-ray results to verify placement of the catheter in the distal end of the superior vena cava.

1) h. Obtain chest x-ray results to verify placement of the catheter in the distal end of the superior vena cava. 2) e. Assess the CVAD insertion site for redness, edema, warmth, drainage, and pain. 3) a. Perform hand hygiene. 4) c. Use strict sterile technique to change the dressing. 5) f. Use friction to cleanse the CVAD insertion site with chlorhexidine-based preparation. 6) g. Turn the patient's head to the side away from the CVAD insertion site when changing the caps. 7) b. Flush each line with 10 mL of normal saline. 8) d. Clamp unused lines after flushing if not using positive pressure valve caps. The first nursing action after a CVAD is inserted and before it is used is to ensure proper placement with a chest x-ray. Assessments, flushing, dressing changes, and cap changes are completed according to facility policies, but hand hygiene must be completed before manipulating the CVAD to prevent infection. Strict sterile technique is used with dressing and cap changes as well as having the patient turn their face away from the insertion site to avoid contamination.

Which clinical manifestations would the nurse observe when assessing cardiovascular changes in a patient suspected of having a medical diagnosis of fluid volume excess? Select all that apply. 1) Full, bounding pulse 2) Distended neck veins 3) Orthostatic hypotension 4) Increase in the heart rate 5) Presence of an S3 heart sound

A) 1, 2, 5 - Fluid volume excess results in a full, bounding pulse (1); presence of an S3 heart sound (5); and jugular venous distention (distended neck veins) (2). Orthostatic hypotension and an increased heart rate are clinical manifestations of deficient, not excess, fluid volume (3,4).

Which assessments would the nurse perform to avoid risk factors associated with administration of a hypertonic solution to a patient with dehydration? Select all that apply. 1) Lung sounds 2) Bowel sounds 3) BP 4) Serum sodium level 5) Serum potassium level

A) 1, 3, 4 - BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions (3,1,4). Bowel sounds and serum potassium levels do not need to be monitored frequently (2,5).

Which grade of edema would the nurse document when the patient's skin is cool, sternal skin is taut, and sternal pressure with a thumb yields a 2-mm indentation?

A) 1+ - Cool, taut, and hard skin indicates fluid accumulation. An indentation of 2-mm after pressing with the thumb to assess edema indicates a grade of 1+. A 4-mm indentation warrants a grade of 2+, a 6-mm indentation a grade of 3+, and an 8-mm indentation a grade of 4+.

Which patient outcome would the nurse use to evaluate the effectiveness of the treatment regimen for a patient's dehydration?

A) Oral intake balances output. - Oral intake should equal output if fluid balance has been restored and dehydration has been corrected. Less intake than output would result in dehydration. Greater intake than output may indicate decreased renal function or impaired ability to excrete urine.

After removing 5 liters of fluid during a patient's paracentesis, which IV solution may be used to pull fluid into the intravascular space?

A) 25% albumin solution

To provide free water and intracellular fluid hydration for a patient with acute gastroenteritis who is NPO, the nurse would expect administration of which infusion? a. Dextrose 5% in water b. Dextrose 10% in water c. Lactated Ringer's solution d. Dextrose 5% in normal saline (0.9%)

Fluids such as 5% dextrose in water (D5W) allow water to move from the ECF to the ICF. Although D5W is physiologically isotonic, the dextrose is rapidly metabolized, leaving free water to shift into cells.

Match the following descriptions with the mechanisms of fluid and electrolyte movement. a. Force exerted by a fluid 1. Osmosis b. Uses a protein carrier molecule 2. Diffusion c. Pressure exerted by plasma 3. Active transport proteins 4. Oncotic pressure d. Adenosine triphosphate (ATP) 5. Osmotic pressure e. Force determined by osmolality 6. Facilitated diffusion of a fluid 7. Hydrostatic pressure f. Flow of water from low-solute concentration to high-solute concentration g. Passive movement of molecules from a high concentration to lower concentration

a. Force exerted by a fluid = Hydrostatic pressure b. Uses protein carrier molecule = Facilitated diffusion c. Oncotic pressure = Pressure exerted by plasma d. Adenosine triphosphate (ATP) = Active transport e. Force determined by fluid osmolality = Osmotic pressure f. Flow of water from low-solute concentration to high- solute concentration = Osmosis g. Passive movement of molecules from a high concentration to lower concentration = Diffusion

The nurse is admitting a patient to the clinical unit from surgery. Being alert to potential fluid volume alterations, what assessment data will be important for the nurse to monitor to identify early changes in the patient's postoperative fluid volume (select all that apply)? a. Intake and output b. Skin turgor c. Lung sounds d. Respiratory rate e. Level of consciousness

a. Intake and output b. Skin turgor c. Lung sounds d. Respiratory rate e. Level of consciousness All of these are important in assessing fluid balance in a postoperative patient. Daily weight along with these assessments will provide data about potential fluid volume abnormalities.

Match the electrolyte imbalances with their associated causes (answers may be used more than once and imbalances may have more than 1 associated cause). Electrolyte Imbalance Cause a. Metabolic alkalosis 1. Hypernatremia b. Parathyroidectomy 2. Hyponatremia c. Diabetes insipidus 3. Hyperkalemia d. Fleet enemas 4. Hypokalemia e. Primary polydipsia 5. Hypercalcemia f. Excess milk of magnesia use 6. Hypocalcemia g. Early burn stage 7. Hyperphosphatemia h. Chronic alcoholism 8. Hypophosphatemia i. Vitamin D deficiency 9. Hypermagnesemia j. Osmotic diuresis 10. Hypomagnesemia k. Prolonged immobilization l. Hyperaldosteronism m. Chronic kidney disease n. Loop and thiazide diuretics

a. Metabolic alkalosis = Hypokalemia b. Parathyroidectomy = Hypocalcemia c. Diabetes insipidus = Hypernatremia d. Fleet enemas = Hypernatremia/Hypokalemia/ Hypocalcemia/Hyperphosphatemia e. Primary polydipsia = Hyponatremia f. Excess milk of magnesia use = Hypokalemia/ Hypophosphatemia/Hypermagnesemia g. Early burn stage = Hyponatremia/Hyperkalemia h. Chronic alcoholism = Hypokalemia/Hypocalcemia/ Hypophosphatemia/Hypomagnesemia i. Vitamin D deficiency = Hypocalcemia/ Hypophosphatemia j. Osmotic diuresis = Hypernatremia/Hypokalemia k. Prolonged immobilization = Hypercalcemia l. Hyperaldosteronism = Hypernatremia/Hypokalemia m. Chronic kidney disease = Hyperkalemia/ Hypocalcemia/Hyperphosphatemia/ Hypermagnesemia n. Loop and thiazide diuretics = Hypernatremia/ Hyponatremia/Hypokalemia/Hypercalcemia/ Hypocalcemia

What are characteristics of the phosphate buffer system (select all that apply)? a. Neutralizes a strong base to a weak base and water b. Resultant sodium biphosphate is eliminated by kidneys c. Free acid radicals dissociate into H+ and CO2, buffering excess base d. Neutralizes a strong acid to yield sodium biphosphate, a weak acid, and salt e. Shifts chloride in and out of red blood cells in exchange for sodium bicarbonate, buffering both acids and bases

a. Neutralizes a strong base to a weak base and water b. Resultant sodium biphosphate is eliminated by kidneys d. Neutralizes a strong acid to yield sodium biphosphate, a weak acid, and salt Base neutralization to a weak base, water, and salt and elimination of sodium biphosphate by the kidneys are characteristic of the phosphate buffer system. Free acid radical dissociation is characteristic of the protein buffer system. Chloride shifting in and out of red blood cells is characteristic of the hemoglobin buffer system.

The nurse is reviewing a patient's morning laboratory results. Which result is of greatest concern? a. Serum Na+ of 150 mEq/L b. Serum Mg2+ of 1.1 mEq/L c. Serum PO4 3− of 4.5 mg/dL d. Serum Ca2+ (total) of 8.6 mg/dL

b. Serum Mg2+ of 1.1 mEq/L With a low magnesium level there is an increased risk for hypokalemia and hypocalcemia as well as altered sodium-potassium pump and altered carbohydrate and protein metabolism. Hypokalemia could lead to dysrhythmias and severe muscle weakness. The sodium and phosphate levels are also not within normal limits. However, the implications are not as life-threatening. The calcium level is normal.

A patient with chronic kidney disease has hyperphosphatemia. What is a commonly associated electrolyte imbalance? a. Hypokalemia b. Hyponatremia c. Hypocalcemia d. Hypomagnesemia

c. Hypocalcemia Kidneys are the major route of phosphate excretion, a function that is impaired in renal failure. A reciprocal relationship exists between phosphorus and calcium, and high serum phosphate levels of kidney failure cause low calcium concentration in the serum.

As fluid circulates through the capillaries, there is movement of fluid between the capillaries and interstitium. What describes the fluid movement that would cause edema (select all that apply)? a. Plasma hydrostatic pressure is less than plasma oncotic pressure. b. Plasma oncotic pressure is higher than interstitial oncotic pressure. c. Plasma hydrostatic pressure is higher than plasma oncotic pressure. d. Plasma hydrostatic pressure is less than interstitial hydrostatic pressure. e. Interstitial hydrostatic pressure is lower than plasma hydrostatic pressure.

c. Plasma hydrostatic pressure is higher than plasma oncotic pressure. e. Interstitial hydrostatic pressure is lower than plasma hydrostatic pressure. At the arterial end of the capillary, capillary hydrostatic pressure exceeds plasma oncotic pressure and fluid moves into the interstitial space. At the capillary level, hydrostatic pressure is the major force causing fluid to shift from vascular to the interstitial space. The other options would not cause edema.

In a patient with sodium imbalances, the primary clinical manifestations are related to alterations in what body system? a. Kidneys b. Cardiovascular system c. Musculoskeletal system d. Central nervous system

d. Central nervous system As water shifts into and out of cells in response to the osmolality of the blood, the cells that are most sensitive to shrinking or swelling are those of the brain, resulting in neurologic symptoms.

What is a compensatory mechanism for metabolic alkalosis? a. Shifting of bicarbonate into cells in exchange for chloride b. Kidney conservation of bicarbonate and excretion of hydrogen ions c. Deep, rapid respirations (Kussmaul respirations) to increase CO2 excretion d. Decreased respiratory rate and depth to retain CO2 and kidney excretion of bicarbonate

d. Decreased respiratory rate and depth to retain CO2 and kidney excretion of bicarbonate Decreased respiratory rate and kidney excretion of HCO3− compensates for metabolic alkalosis. Shifting of bicarbonate for Cl− may buffer acute respiratory alkalosis. The kidney conserves bicarbonate and excretes hydrogen to compensate for respiratory acidosis. Kussmaul respirations occur with metabolic acidosis to compensate.

What stimulates aldosterone secretion from the adrenal cortex? a. Excessive water intake b. Increased serum osmolality c. Decreased serum potassium d. Decreased sodium and water

d. Decreased sodium and water Aldosterone is secreted by the adrenal cortex in response to a decrease in plasma volume (loss of water) and resulting decreased renal perfusion; decreased serum sodium, increased serum potassium, or adrenocorticotropic hormone (ACTH).

Which patient is at risk for hypernatremia? a. Has an aldosterone deficiency b. Has prolonged vomiting and diarrhea c. Receives excessive IV 5% dextrose solution d. Has impaired consciousness and decreased thirst sensitivity

d. Has impaired consciousness and decreased thirst sensitivity A major cause of hypernatremia is a water deficit, which can occur in those with a decreased sensitivity to thirst, the major protection against hyperosmolality. All other conditions lead to hyponatremia.

Which clinical manifestation would the nurse relate to a patient's body temperature of 103° F (39.4° C)?

A) Orthostatic hypotension - Orthostatic or postural hypotension is the clinical manifestation the nurse should anticipate observing when assessing a patient with a body temperature of 103° F (39.4° C). The febrile patient will have reduced blood volume from fluid loss due to sweating and increased insensible water loss, as well as vasodilation from heat. Although a reduced blood volume with an elevated temperature would produce an increased pulse rate, it would not be a bounding pulse. Muscle spasm, a bounding pulse, and jugular vein distention are manifestations of an increase (not a decrease) in blood volume.

Which process of molecule transport would occur when a patient develops pedal edema and their blood pressure is 160/90 mm Hg?

A) Osmosis - A patient with blood pressure of 160/90 mm Hg has hypertension and develops pedal edema due to excess sodium in the blood. This leads to movement of water down the gradient. Therefore the water from the blood vessels moves from higher concentrations to lower concentration across the semipermeable membrane with the help of osmotic pressure and leads to accumulation of water in the extracellular spaces. This movement of water across a semipermeable membrane to balance the solute is called osmosis. Diffusion and facilitated diffusion involve molecules moving from a higher to lower concentrations, and active transport involves molecules moving from a lower to higher concentration.

Which patient disorder has a potential complication of developing increased extracellular fluids?

A) Renal impairment - Extracellular fluid accounts for one-third of total body fluids, which consist of interstitial fluid, plasma, and transcellular fluid. The extracellular fluid may become excessive when the elimination of water is impaired, especially during kidney failure. Conditions such as fistula drainage, osmotic diuresis, and intestinal obstruction result in a loss of body fluid.

Fill in the blanks in the subsequent table using the possible answer choices given in the columns below the table to indicate the direction of fluid shift and the mechanism of fluid movement that is involved (answers may be used more than once). Event or Factor - Burns - Dehydration - Fluid overload - Hyponatremia - Low serum albumin - Administration of 10% glucose - Application of elastic bandages Direction of Fluid Shift Mechanism of Fluid Movement Involved 1. From blood vessels to a. Osmosis interstitium b. Plasma hydrostatic pressure 2. From extracellular c. Interstitial hydrostatic pressure compartment to the cell d. Tissue oncotic pressure 3. From cell to extracellular e. Oncotic pressure compartment 4. From interstitium to vessels

- Burns: 1. From blood vessels to interstitium b. Plasma hydrostatic pressure - Dehydration: 2. From extracellular compartment to the cell c. Interstitial hydrostatic pressure - Fluid overload: 3. From cell to extracellular compartment 4. From interstitium to vessels d. Tissue oncotic pressure - Hyponatremia: 4. From interstitium to vessels a. Osmosis - Low serum albumin: 1. From blood vessels to interstitium c. Interstitial hydrostatic pressure - Administration of 10% glucose: 1. From blood vessels to interstitium a. Osmosis - Application of elastic bandages: 4. From interstitium to vessels c. Interstitial hydrostatic pressure

CASE STUDY: Fluid and Electrolyte Imbalance Patient Profile: P.B., a 69-year-old woman who lives alone, is admitted to the hospital because of weakness and confusion. She has a history of chronic heart failure and chronic diuretic use. Objective Data Physical Examination • Neurologic: Confusion, slow to respond to questioning, generalized weakness • Cardiovascular: BP 90/62 mm Hg, HR 112 bpm and irregular, peripheral pulses weak; ECG shows sinus tachycardia • Pulmonary: RR 12 and shallow • Other findings: Decreased skin turgor, dry mucous membranes Laboratory Results • Serum electrolytes + Na+: 141 mEq/L (141 mmol/L) + K+: 2.5 mEq/L (2.5 mmol/L) + Cl−: 85 mEq/L (85 mmol/L) • HCO3−: 34 mEq/L (34 mmol/L) • BUN: 42 mg/dL (15 mmol/L) • Hct: 49% • Arterial blood gases + pH: 7.52 + PaCO2: 55 mm Hg + PaO2: 88 mm Hg + HCO3 −: 34 mEq/L (34 mmol/L) Discussion Questions 1. Evaluate P.B.'s fluid volume and electrolyte status. Which physical assessment findings support your analysis? Which laboratory results support your analysis? What is the most likely cause of these imbalances? 2. Explain the reasons for her ECG changes. 3. Analyze the arterial blood gas results. What is the etiology of the primary imbalance? Is the body compensating for this imbalance? 4. Why has P.B.'s advanced age placed her at risk for fluid imbalance? 5. Discuss the role of aldosterone in the regulation of fluid and electrolyte balance. How will changes in aldosterone affect P.B.'s fluid and electrolyte imbalances? 6. Priority Decision: Develop a plan of care for P.B. while she is in the hospital. What are the priority daily assessments that should be included in this plan of care? 7. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems? 8. Patient-Centered Care: What should P.B. be taught before she is dismissed?

1. Fluid volume deficit Physical assessment: decreased skin turgor, dry mucous membranes, weak pulses, low BP, confusion Laboratory findings: elevated blood urea nitrogen (BUN), elevated hematocrit Electrolyte status: hypokalemia Physical assessment: weakness, confusion; irregular heart rhythm, tachycardia Laboratory findings: potassium 2.5 mEq/L Etiology: diuretic therapy 2. Electrocardiographic (ECG) changes are associated with hypokalemia and metabolic alkalosis. 3. Metabolic alkalosis: pH 7.52 with increased base bicarbonate (34 mEq/L) Etiology: diuretic-induced hypokalemia is the primary factor. Compensation: not complete because the pH is out of normal range, but increased PaCO2 and slow and shallow respirations show the attempt by the lungs to increase CO2 to compensate for excess bicarbonate. 4. P.B. has less fluid reserve because older adults have less total body fluid; older adults also have decreased thirst sensation. 5. Aldosterone would be secreted in response to low fluid volume (decreased plasma volume). P.B.'s low BP and ECF deficit would stimulate secretion of aldosterone to increase sodium and water retention. 6. General care: encourage and assist with oral fluid intake. Provide skin care with assessment, changes in position, no soap. Assessments • Vital signs q4hr • Intake and output; daily weights • Cardiac monitoring until electrolytes and acid-base normal • Type and rate of IV fluid and electrolyte replacement • Lung sounds for signs of fluid overload in cardiac-compromised patient • Daily serum electrolyte and blood gas levels 7. Nursing diagnoses • Fluid imbalance; Etiology: excessive ECF loss or decreased fluid intake • Lack of knowledge; Etiology: lack of knowledge of drugs and preventive measures • Risk for injury; Etiology: confusion, muscle weakness • Risk for impaired tissue integrity; Etiology: dehydration Collaborative problems Potential complications: dysrhythmias, hypovolemic shock, hypoxemia 8. Teach P.B. health maintenance behaviors (e.g., take medications as ordered, how to monitor effects of medications with BP, daily weight, checking for edema; drink at least 1500 mL water daily, drink fluids even without thirst; keep appointments with HCP).

For a patient with heart failure, which interventions would the nurse include in the plan of care when the patient has 4+ edema of the lower extremities and sacral area? Select all that apply. 1) Elevate edematous lower extremities. 2) Protect the patient's tissues from extreme heat or cold. 3) Apply moisturizing creams or lotions to the skin frequently. 4) Rotate the patient from left side-lying to right side-lying every two hours. 5) Frequently assess for edema in areas where soft tissue covers bony areas. 6) Encourage the patient to double fluid intake to improve tissue integrity.

A) 1, 2, 3, 5 - Providing proper skin care is vitally important in patients dealing with edema to prevent impaired skin and tissue integrity. Elevating the edematous extremities helps promote venous return (1). Protecting the patient's tissues from extreme hot or cold decreases the possibility of skin or tissue impairment (2). Applying moisturizers to the skin frequently promotes moisture retention and stimulates circulation (3). Edema tends to accumulate in areas where tissue overlies bone such as the sacrum, tibia, and fibula and must be assessed frequently to avoid the risk of pressure ulcers (5). The patient's position should be frequently changed but is not restricted to side-lying (4). There is not enough data to determine the fluid needs of the patient, and this is not a standard intervention but is based upon patient need (6).

Which patient statements indicate understanding of nursing instructions regarding skin care management? Select all that apply. 1) "Avoid extreme temperatures." 2) "Apply moisturizers even at night." 3) "Wash my hands and legs frequently with soap." 4) "Change my position regularly while at rest." 5) "I will not use the foot lift on my recliner."

A) 1, 2, 4 - Good skin care management is essential to prevent fluid loss. The patient should limit the use of soap to prevent the skin from drying (3). The nurse should advise the patient to either take precautions or to avoid extreme temperatures in order to avoid dehydration of the skin (1). Regular skin care by applying moisturizers and changing positions while at rest helps to maintain skin hydration and may prevent skin breakdown (2,4). Elevation of extremities promotes venous return, so the patient would elevate the feet when in a recliner (5).

Which clinical manifestations would the nurse evaluate for the presence of dehydration in the older adult patient admitted with nausea and vomiting? Select all that apply. 1) Hypertension 2) Bradypnea 3) Tachycardia 4) Restlessness 5) Urine output 10 mL/hr

A) 3, 4, 5 - Decreased urine output below 30 mL/hour, tachycardia, and restlessness are all signs of dehydration (3,4,5). Dehydration will cause hypotension and would increase, not decrease, respiratory rate (1,2).

Which interventions would the nurse perform prior to removing a patient's central venous access device (CVAD)? Select all that apply. 1) Understand the scope of nursing practice. 2) Review the health care provider's prescription. 3) Request a second nurse to assist with the removal. 4) Review the health care organization's policy on the procedure. 5) Provide pharmacologic intervention prior to removing the CVAD.

A) 1, 2, 4 - Not all health care agencies allow a nurse to perform this procedure. Prior to removing a patient's CVAD, the nurse should know the health care organization's policy (4), confirm that the removal is in the scope of a registered nurse's practice to perform (1), and review the health care provider's prescription (2). It is not necessary to have another nurse assist with the removal of a CVAD or to routinely medicate the patient (3,5).

Which actions would the nurse implement immediately when a patient with a central venous access device begins to experience chest pain, dyspnea, hypotension, and tachycardia? Select all that apply. 1) Administer oxygen. 2) Administer anticoagulants. 3) Clamp the central venous access catheter. 4) Place the patient on the left side with the head down. 5) Flush the central venous access device with normal saline using a 10 mL syringe.

A) 1, 3, 4 - Pulmonary embolism is a complication of central venous access devices. The nurse should start oxygen therapy to relieve dyspnea (1). The catheter should be clamped to prevent further formation of emboli (3). Because the signs suggest air embolism, the patient is placed on the left side with the head down (4). Administering anticoagulants and normal saline are required if the catheter is occluded, and they do not help in relieving a pulmonary embolus (2,5).

The nurse provided care instructions for an older adult patient's dementia and fluid balance maintenance at home. Which caregiver statements indicate understanding of the nurse's teachings? Select all that apply. 1) "I should increase fluid intake and lower dietary sodium." 2) "I should provide fluids only when the patient voices thirst." 3) "I should assist the patient when holding utensils and cups." 4) "I should encourage the patient to pass urine before going to bed." 5) "I will make sure the patient has a glass of milk near them all the time."

A) 1, 3, 4 - The caregiver would decrease the patient's dietary sodium intake (1). Musculoskeletal changes such as stiffness of the hands and fingers may lead to an inability to hold containers and requires assistance (3). The patient should make a habit of urinating before bed to decrease the chance of nocturia (4) . Mental status alterations are a common problem in old age and may lead to decreased ability to express thirst and obtain fluids. Therefore older adult patients are always encouraged to drink fluids, even when they are not requesting them (2). The patient would need to increase their intake of other fluids, with water being the better fluid source (5).

Which clinical manifestations support a patient's admitting diagnosis of fluid volume excess related to heart failure? Select all that apply. 1) Polyuria 2) Dizziness 3) Lung crackles 4) Muscle spasms 5) Peripheral edema 6) Increased respiratory rate

A) 1, 3, 4, 5 - Heart failure can cause fluid volume excess, which is characterized by polyuria (1), fluid in the lungs causing crackles (3), muscle spasms (4), and peripheral edema (5). Dizziness and increased respiratory rate are clinical manifestations of fluid volume deficit, not excess (2,6).

For the patient with a central venous access, which interventions would the nurse implement to maintain a safe, functioning device? Select all that apply. 1) Change the catheter dressing regularly. 2) Monitor the heart rate and BP. 3) Cleanse around the catheter insertion site. 4) Measure and record oral intake and output. 5) Change the injection caps at regular intervals.

A) 1, 3, 5 - Nursing management of central venous access devices is important in keeping the devices safe and functioning and in reducing risk of infection. The catheter dressing and the injection caps should be regularly changed (1,5), and the catheter site should be regularly cleansed (3); these steps keep the site free from infection. Flushing is an important intervention to maintain the patency of the catheter and prevent occlusion. Monitoring vital parameters and assessing intake and output are general measures that are not specific to the care of central venous access devices (2,4).

Which disorders would the nurse associate with a patient's increased BP, peripheral edema, dyspnea, jugular venous distention, and complaint of a headache? Select all that apply. 1) Heart failure 2) Hemorrhage 3) Diabetic insipidus 4) Long-term use of corticosteroids 5) Syndrome of inappropriate antidiuretic hormone (SIADH)

A) 1, 4, 5 - Excess volume of fluid can accumulate in illnesses such as heart failure and SIADH, or due to long-term use of corticosteroids. In heart failure, the heart is unable to pump adequate blood to the body, resulting in pooling of blood in the periphery (1). In SIADH, abnormal levels of ADH cause reabsorption of water from the kidneys, leading to water retention in the body (5). Long-term use of corticosteroids causes altered homeostatic regulation of sodium and water, resulting in excess fluid volume (4). Hemorrhage and diabetic insipidus cause a deficit in fluid volume (2,3).

Which nursing interventions would the nurse implement when unable to infuse fluids via the patient's central venous access device? Select all that apply. 1) Assess the catheter for clamping and kinking and alleviate the cause. 2) Instruct the patient to remain supine in bed and not to move. 3) Force-flush the device with normal saline using a 10-mL syringe. 4) Notify radiology of need to perform fluoroscopy to determine the cause and evaluate the site. 5) Consult interventional radiology for administration of anticoagulant or thrombolytic agents.

A) 1, 4, 5 - Occlusion is a common problem with central venous catheters. If occlusion is suspected, the nurse would instruct the patient to change position, raise the arm, and cough, which helps move any blockage (2). The nurse must assess the catheter for clamping and kinking and undo it if found (1). The nurse would inform the health care provider about the catheter occlusion so fluoroscopy can be performed if needed to determine the cause and site of occlusion (4). In addition, anticoagulants or antithrombolytic agents can be administered (5). Having the patient lie supine and motionless is not appropriate when assessing possible occlusion (2). Flushing is a very important step in maintaining the patency of the catheter. Flushing should be done with normal saline in a 10-mL syringe to avoid pressure on the catheter. Force should not be applied if resistance is felt (3).

How much fluid retention would the nurse document a patient experienced when their admission weight was 60 kg, and the weight on day 2 was 62 kg? Record your answer using a whole number and no punctuation.

A) 2000 mL - One liter of water weighs 2.2 lb (1 kg). Body weight change, especially sudden change, is an excellent indicator of overall fluid volume loss or gain. An increase in 1 kg is equal to 1000 mL of fluid retention. The patient gained 2 kg, which is equal to 2000 mL of fluid retention. 2 kg × 1000 mL = 2000 mL.

Which intervention would the nurse implement when unable to flush a central venous access device due to a suspected occlusion? Select all that apply. 1) Clamp the tubing immediately. 2) Obtain cultures of the insertion site. 3) Instruct the patient to change positions, raise arm, and cough. 4) Attempt to force flush 10 mL of normal saline into the device. 5) Assess the tubing for clamping or kinking, and alleviate as needed.

A) 3, 5 - Catheter occlusion interventions include instructing the patient to change position, raise an arm, and cough (3); assessing for and alleviating clamping or kinking (5); flushing with normal saline using a 10-mL syringe (do not force flush) (4); using fluoroscopy to determine cause and site; and instilling anticoagulant or thrombolytic agents. Clamping the tubing and culturing the site would not assist in flushing the line or resolve the occlusion (1,2). The nurse should not force flush the line (4).

A patient with diabetes mellitus weighs 60 kg and excreted 3500 mL of urine in the last 24 hours. How much weight has the patient lost in the last 24 hours? Record your answer using one decimal place.

A) 3.5 kg - A sudden change in body weight is an indicator of fluid imbalance. One liter of water weighs one kg. Therefore a patient of 60 kg with diabetes mellitus who is excreting 3500 mL of urine per day would lose 3.5 kg. This sudden change of weight is due to polyuria, which further leads to fluid imbalance.

A patient has a serum Na+ of 147 mEq/L (147 mmol/L), blood urea nitrogen (BUN) of 6 mg/dL (2.1 mmol/L), and a blood glucose level of 126 mg/dL (7.0 mmol/L). Plasma osmolality = (2 x Na)+(BUN/2.8)+(Glucose/18) The patient's effective serum osmolality is ________ mOsm/kg. Is the patient's plasma osmolality normal, increased, or decreased?

A) 303.14 The patient's plasma osmolality is increased.

A patient had 500 mL of urine output, vomited 100 mL of clear liquid, and 25 mL of drainage was removed from a wound vacuum device. What number would the nurse record as the total output for this patient? Record your answer as a whole number.

A) 625 mL - The calculation of output includes excessive perspiration, urinary output, vomit, diarrhea, and wound drainage. Totaling 500 mL of urine, 100 mL of vomit, and 25 mL of wound drainage results in 625 mL for the shift.

The patient with an adrenal gland tumor reports feeling unusually sleepy and extremely thirsty. Which action, per protocol, would the nurse implement when the patient is at risk for hypernatremia secondary to primary aldosteronism?

A) Administer furosemide (Lasix) - A tumor of the adrenal glands may cause hypersecretion of aldosterone, resulting in hypernatremia. Hypernatremia should be treated with a diuretic (to promote excretion of excess sodium) and with sodium-free IV fluids such as 5% dextrose in water (to dilute the sodium concentration). Sodium intake should also be restricted. Conivaptan is administered when treating hyponatremia. Normal saline is 0.9% sodium chloride, which increases the amount of sodium; use sodium-free fluids.

In the regulation of water balance, which system's primary effect is antiinflammatory and increases serum glucose levels?

A) Adrenal-cortical - The adrenal-cortical system secretes glucocorticoids and mineralocorticoids to regulate water and electrolyte balance. Glucocorticoids have an antiinflammatory effect and increase serum glucose levels. The renal system regulates water balance through urine volume changes and excretion of electrolytes. The cardiac system produces natriuretic peptides that promote the excretion of sodium and water. The hypothalamic-pituitary system releases antidiuretic hormone, which results in increased water reabsorption into the blood and decreased excretion in the urine.

Which solution would the nurse select as the most effective means of killing harmful bacteria when preparing to cleanse the skin around a central venous access device?

A) Chlorhexidine-based solution - Chlorhexidine-based solutions such as chlorhexidine gluconate have been shown to be more effective at killing bacteria than povidone-alcohol or isopropyl alcohol solutions. Therefore chlorhexidine-based solutions should be used to cleanse around the central venous access device. A sterile saline solution does not have any antiseptic properties.

Which indicator would the nurse use when assessing the fluid balance of a patient being treated for heart failure?

A) Daily weighing - Measuring body weight daily is the most accurate measure of fluid volume status. Skin turgor; intake and output; and BUN, sodium, and hematocrit levels are also indicators of fluid volume status, but these are not as accurate or helpful in gaining information as is daily weighing.

When assessing a patient with Cushing syndrome, which clinical manifestation would the nurse observe?

A) Dyspnea - The nurse would anticipate observing dyspnea in a patient with Cushing syndrome (hyperadrenocorticism) because this condition can cause excess extracellular volume accumulation, which blocks interstitial air and tissue spaces and results in dyspnea, crackles, and peripheral edema. Hypoglycemia, weight loss, and hypotension are the common manifestations of Addison's disease (hypoadrenocorticism).

Which intervention would the nurse implement to relieve the edema associated with a patient's soft tissue injury to their ankle?

A) Elevating the extremity - Elevation promotes good venous return, allowing extracellular fluid to flow more readily away from the edematous area. In addition, ice or a cold compress helps ease edema and pain. Warm saline soaks, massage of the extremity, and warm compresses will increase venous circulation and congestion, thereby worsening the edema, as well as the pain.

For the patient with recent removal of a pituitary tumor, which clinical manifestation would the nurse report immediately to the health care provider? 1) Excessive thirst 2) Calcium level of 8.6 mg/dL 3) Potassium level of 3.5 mEq/L 4) Urine output of 300 mL in eight hours

A) Excessive thirst - A patient who has had surgery on the pituitary gland is at risk for diabetes insipidus. Excessive thirst is an indicator of inadequate antidiuretic hormone (ADH) synthesis or release. The nurse should monitor the urine output closely and notify the health care provider of excessive thirst (1). One would expect large volumes of urine in the absence of ADH production. A urine output of 300 mL in eight hours would not be alarming (4). The calcium and potassium levels are at the low end of normal (2,3). The nurse should continue to monitor these electrolytes.

The nurse prepares to administer a lactated Ringer's IV solution to a patient requiring supportive care after several days of vomiting and diarrhea. Clinical manifestations include a urine specific gravity of 1.040 with 15 mL urine output in one hour, BP 84/48 mm Hg upon standing, and a heart rate of 100 beats/min. The nurse would associate the clinical manifestations and the IV solution with treatment of which imbalance?

A) Extracellular fluid volume deficit - A patient history of vomiting and diarrhea for the past several days, postural hypotension, increased heart rate, and decreased urine output all indicate fluid volume deficit. Balanced IV solutions such as lactated Ringer's solution are commonly used to treat fluid volume deficit. The signs and symptoms do not support a diagnosis of hyponatremia, hyperkalemia, or fluid volume excess.

Which type of imbalance would the nurse associate with a patient who has second-degree (partial-thickness) burns over 30% of the total body surface area with poor skin turgor, urine output of <50 mL over the past two hours, a rapid and thready pulse, and restlessness?

A) Extracellular fluid volume deficit - Patients with burns are susceptible to third-space shifts, resulting in extracellular fluid volume deficit. Extracellular fluid volume deficit is characterized by poor skin turgor, decreased urine output, a rapid and thready pulse, and restlessness. Hyperkalemia is characterized by weakness, irregular pulse, and paresthesias. Hyperphosphatemia is characterized by numbness and tingling, hyperreflexia, tetany, and seizures. Metabolic acidosis is characterized by drowsiness, confusion, decreased BP, dysrhythmias, nausea, and vomiting.

A patient's treatment resulted in blood sugar levels decreasing from 210 mg/dL to 150 mg/dL. Which method of fluid movement between intracellular and extracellular fluids support the effectiveness of the patient's treatment?

A) Facilitated diffusion - Facilitated diffusion is a process that involves the movement of molecules from higher concentrations to lower concentrations by a protein carrier across the membrane. It is a passive process in which the glucose molecules are transported into the cell by combining with the carrier molecule from extracellular fluid to intracellular fluid. Osmosis allows transport of molecules from lower concentration to higher concentration across the semipermeable membrane. It occurs mainly during urine formation in the kidneys. Diffusion is a simple process of movement of molecules from higher to lower concentration. Active transport is a process similar to diffusion but occurs in the presence of external energy.

Which clinical manifestations would indicate a patient with heart failure is at risk for developing fluid volume excess?

A) Full, bounding pulse - Any change in the fluid volume is reflected in changes in blood pressure, pulse rate force, and jugular venous distension. A fluid volume excess may cause a full, bounding pulse; increased blood pressure; and distended neck veins. The pulse in this case is not easily obliterated. Flattened neck veins, low blood pressure, and a weak and thready pulse that can be easily obliterated indicate fluid volume deficit.

Which clinical manifestation would the nurse associate with the patient's admitting problem of deficient fluid volume related to nausea and vomiting?

A) General restlessness - Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma. Polyuria, decreased pulse, and difficulty breathing do not support a determination of deficient fluid volume.

When preparing to administer IV albumin 5% to a patient, the nurse understands the solution is used to treat which metabolic alteration?

A) Hypovolemia - Albumin is a colloid solution that pulls fluid into the blood vessels, which restores blood volume. This medication is used to treat hypovolemia. Albumin is not effective in the treatment of alkalosis, hyperkalemia, or a mixed acid-base disorder.

Which action will the nurse take for a patient with overuse of diuretics based on the BP readings below? [Lying]: 132/84 [Sitting]: 110/78 [Standing]: 92/62

A) Implement fall precautions. - The patient with overuse of diuretics is likely to have fluid volume deficit. A drop in BP while changing positions is orthostatic hypotension and should have fall precautions implemented. The patient with fluid volume excess may require oxygen, would be monitored through pulse oximetry, and should be assessed for rales in the lungs.

A patient with heart failure accidentally overused the prescribed diuretics. For which potential respiratory manifestation would the nurse monitor?

A) Increased respiratory rate - Patients with deficient fluid volume experience decreased tissue perfusion and hypoxia resulting in an increased respiratory rate. Pulmonary congestion, shortness of breath, and moist crackles on inspiration are all characteristic of a fluid volume excess, not deficit.

A patient with a diagnosis of heat stroke has a urine output of 4000 mL/day. Which intervention would the nurse implement?

A) Initiate infusion of lactated Ringer's solution. - Heat stroke and an increased amount of urine output of about 4000 mL leads to a deficit in extracellular fluid volume, causing dehydration. Administering lactated Ringer's solution to maintain fluid and electrolyte balance is beneficial. Blood transfusions are performed only when the fluid loss is due to blood loss. Moisturizers are applied to patients with dry skin to prevent the fluid loss. Tube feeding is preferred in the patient with severe extracellular fluid loss. The patient on tube feedings must be supplemented with water added to the enteric formula.

Which health care provider prescription will the nurse implement when admitting a patient with fluid volume deficit due to severe diarrhea?

A) Insert an IV access and infuse lactated Ringer's solution. - To correct fluid volume deficit due to severe diarrhea, the nurse should anticipate a prescription for lactated Ringer's solution which is isotonic and replaces fluid and electrolytes. Giving hypertonic sodium chloride would exacerbate the patient's dehydration. A blood transfusion would be given if the fluid volume deficit was due to blood loss and not dehydration. Sodium intake should be restricted in case of fluid volume excess.

When extracellular fluid and intracellular fluid have the same osmolality, which term would the nurse use?

A) Isotonic - Extracellular fluid and intracellular fluid have the same osmolality; this characteristic is termed isotonic, meaning that there is no net movement of fluids. Hypotonic refers to fluids with a lower osmolality, which results in water moving into the cell when the cell is surrounded by a hypotonic fluid. Hypertonic refers to fluids with a higher osmolality, which results in water moving out of the cells when they are surrounded by a hypertonic solution. Oncotic pressure refers to the pressure of plasma colloids in a solution.

A patient's intravenous (IV) fluid is ordered to infuse at 125 mL/hr. At 0800, the nurse notes 950 mL of fluid has infused from a bag hung at 0400. Which action will the nurse take first? 1) Notify the health care provider and complete an incident report. 2) Hang a new bag of IV solution to maintain patency of the site. 3) Listen to the patient's lung sounds and assess respiratory status. 4) Discontinue the fluids and saline lock the IV access until the next scheduled bag.

A) Listen to the patient's lung sounds and assess respiratory status. - After four hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and the nurse will assess the patient's respiratory status and lung sounds as the priority action (3) and then notify the health care provider for further orders (1). Discontinuing the IV fluids and saline locking the IV access until the next scheduled bag is not a viable option as the nurse may need to administer a diuretic IV (4). The nurse may obtain and hang a new bag of IV solution to keep the site patent, but it would have to be slowed to a keep vein open (KVO) rate until the respiratory status is determined and the provider notified. Continuing fluid infusing at the ordered rate to maintain access puts the patient at further risk (2).

To which patient does the nurse apply pulse oximetry? 1) Patient 1 - (Dx): New onset of HF; (s/s): Taut, edematous skin 2) Patient 2 - (Dx): Diabetes insipidus; (s/s): Dry skin w/ tenting 3) Patient 3 - (Dx): Prolonged N&V; (s/s): Cool, clammy skin 4) Patient 4 - (Dx): Heatstroke; (s/s): Moist, warm skin

A) Patient 1 - Patient 1 with heart failure and fluid volume excess would be monitored with pulse oximetry to track oxygenation. Patients 2, 3, and 4 are in situations of fluid volume deficit that do not place the lungs at risk for impaired gas exchange, therefore not requiring pulse oximetry.

Of the four patients receiving care, which patient's chart leads the nurse to suspect development of a fluid volume deficit? 1) Patient A - (Dx): Diabetes insipidus; (s/s): restlessness, decreased skin turgor and capillary refill, urine specific gravity = 1.037 2) Patient B - (Dx): Heart failure; (s/s): HA, polyuria, dyspnea, urine specific gravity = 1.003 3) Patient C - (Dx): Heat stroke; (s/s): flushed skin, N&V; urine specific gravity = 1.025 4) Patient D - (Dx): Syndrome of inappropriate antidiuretic hormone (SIADH); (s/s): generalized muscle weakness, hyporeflexia, urine specific gravity = 1.008

A) Patient A - The clinical manifestations of fluid volume depletion include restlessness, decreased skin turgor, decreased capillary refill, and concentrated urine and can be caused by diabetes insipidus, so Patient A is the correct answer. Heart failure—as in Patient B—can be a cause of fluid volume excess, not deficit. Heatstroke—as in Patient C—can be a cause of fluid volume deficit; however, in this case the urine specific gravity is within normal limits, and flushed skin, nausea, and vomiting are signs of heatstroke. SIADH—as in Patient D—can be a cause of fluid volume excess, not deficit.

Which intervention would the nurse implement when a pregnant patient reports headaches and shortness of breath and the nurse auscultates crackles and a bounding pulse?

A) Restrict the intake of dietary sodium. - A pregnant woman with increased extracellular fluid may develop hypertension and pregnancy-related complications. Restriction of dietary sodium helps to control the fluid accumulation and may help to maintain fluid balance. Application of warm and cold compresses will not relieve the patient's symptoms. Changing the position does not benefit the patient, and providing ice chips may increase the fluid volume and worsen the condition.

Which data findings would the nurse instruct the unlicensed assistive personnel (UAP) to report while providing care for an older adult patient with dehydration? 1) Temperature 97.1°F (36.2°C) 2) Frequent use of the urinal 3) Urine output of 350 mL in 24 hours 4) Ambulation in the hallway without assistance

A) Urine output of 350 mL in 24 hours - KCl is only administered when the urine output is at least 0.5 mL/kg of body weight per hour. Consider the situation if an adult patient weighed 150 lbs. Dividing this weight by 2.2 kg results in an outcome of 68.18 kg. Then multiply the body weight by the minimal urine output of 0.5 mL, which shows that the patient needs to put out approximately 34 mL/hr. Then divide the 350 mL by 24, which shows that the patient is only producing 14.58 mL/hr and is well below the minimal urine output required by an adult patient. The minimal urine output necessary to maintain kidney function is 30 mLs per hour or 720 mL per 24 hours. The nurse should be notified of a decrease in urine output so that additional fluid volume-replacement therapy can be instituted (3). Ambulation is encouraged (4). The temperature is normal (1). Frequent use of the urinal would not indicate dehydration (2).

Which mechanism would the nurse use to explain a patient's insensible water loss of an estimated 900 mL/day?

A) Vaporized by the lungs and skin - Approximately 600-900 mL of water is lost each day via insensible water loss, which is vaporization by the lungs and skin. Approximately 1500 mL is excreted in the urine and 100 mL in the feces. Approximately 8000 mL of digestive fluids are secreted daily, but most are reabsorbed in the gastrointestinal tract.

A woman has ham with gravy and green beans cooked with salt pork for dinner. a. What could happen to the woman's serum osmolality because of this meal? b. What fluid regulation mechanisms are stimulated by the intake of these foods?

a) Serum osmolality increases as a large amount of sodium is absorbed. b) Intake of these foods stimulates antidiuretic hormone (ADH) release from the posterior pituitary, which increases water reabsorption from the kidney, lowering the sodium concentration but increasing vascular volume and hydrostatic pressure, perhaps causing fluid shift into interstitial spaces.

A patient is scheduled to have a tunneled catheter placed for administration of chemotherapy for breast cancer. When preparing the patient for the catheter insertion, what does the nurse explain about this method of chemotherapy administration? a. Decreases the risk for extravasation at the infusion site b. Reduces the incidence of systemic side effects of the drug c. Does not become occluded as peripherally inserted catheters can d. Allows continuous infusion of the drug directly to the area of the tumor

a. Decreases the risk for extravasation at the infusion site Catheters tunneled to the distal end of the superior vena cava or the right atrium are vascular access devices inserted into central veins, which decrease the incidence of extravasation, provide for rapid dilution of chemotherapy, and reduce the need for venipunctures. Most right atrial catheters, except for a Groshong catheter, must be flushed with heparin to prevent clotting in the tubing. Regional chemotherapy administration delivers the drug directly to the tumor and is the only administration route that can decrease the systemic effects of the drugs.

Match the acid-base imbalances with their common causes (answers may be used more than once). Cause Acid-Base Imbalance a. Renal failure 1. Metabolic acidosis b. Severe shock 2. Metabolic alkalosis c. Diabetic ketosis 3. Respiratory acidosis d. Respiratory failure 4. Respiratory alkalosis e. Prolonged vomiting f. Baking soda used as antacid g. Mechanical over ventilation h. Sedative or opioid overdose i. Response to anxiety, fear, and pain

a. Renal failure = Metabolic acidosis b. Severe shock = Metabolic acidosis c. Diabetic ketosis = Metabolic acidosis d. Respiratory failure = Respiratory acidosis e. Prolonged vomiting = Metabolic alkalosis f. Baking soda used as antacid = Metabolic alkalosis g. Mechanical over ventilation = Respiratory alkalosis h. Sedative or opioid overdose = Respiratory acidosis i. Response to anxiety, fear, and pain = Respiratory alkalosis

What are the characteristics of the carbonic acid-bicarbonate buffer system (select all that apply)? a. The lungs eliminate CO2 b. Neutralizes HCl acid to yield carbonic acid and salt c. H2CO3 formed by neutralization dissociates into H2O and CO2 d. Shifts H+ in and out of cell in exchange for other cations, such as potassium and sodium e. Free basic radicals dissociate into ammonia and OH−, which combines with H+ to form water

a. The lungs eliminate CO2 b. Neutralizes HCl acid to yield carbonic acid and salt c. H2CO3 formed by neutralization dissociates into H2O and CO2 CO2 elimination by the lungs, neutralized HCl, and H2CO3 formation are all part of the carbonic acid-bicarbonate buffer system. Shifts of H+ in and out of the cell are characteristics of the cellular buffer system. Free basic radical dissociation is characteristic of the protein buffer system.

Which statement(s) about fluid in the human body is (are) true (select all that apply)? a. The primary hypothalamic mechanism of water intake is thirst. b. Third spacing refers to the abnormal movement of fluid into interstitial spaces. c. A cell surrounded by hypoosmolar fluid will shrink and die as water moves out of the cell. d. A cell surrounded by hyperosmolar fluid will shrink and die as water moves out of the cell. e. Concentrations of Na+ and K+ in interstitial and intracellular fluids are maintained by the sodium-potassium pump.

a. The primary hypothalamic mechanism of water intake is thirst. d. A cell surrounded by hyperosmolar fluid will shrink and die as water moves out of the cell. e. Concentrations of Na+ and K+ in interstitial and intracellular fluids are maintained by the sodium-potassium pump. With fluid volume deficit, the osmoreceptors stimulate thirst. Hyperosmolar extracellular fluid (ECF) draws fluid out of the cells. The sodium-potassium pump maintains the fluid balance between the intracellular fluid (ICF) and ECF. Third spacing is when fluid moves into spaces that normally have little or no fluid. A cell surrounded by hypoosmolar fluid will swell and burst as water moves into the cell.

A patient with a pH of 7.29 has metabolic acidosis. Which value is useful in determining whether the cause of the acidosis is an acid gain or a bicarbonate loss? a. PaCO2 b. Anion gap c. Serum Na+ level d. Bicarbonate level

b. Anion gap Anion Gap = Na+ − (HCO3 − + Cl−). Calculate the anion gap by subtracting the serum bicarbonate and chloride levels from the serum sodium level. It should normally be 8 to 12 mmol/L. The anion gap is increased in metabolic acidosis associated with acid gain (e.g., diabetic ketoacidosis) but is normal in metabolic acidosis caused by bicarbonate loss (e.g., diarrhea).

A patient is taking diuretic drugs. Which fluid or electrolyte imbalance can occur in this patient (select all that apply)? a. Hyperkalemia b. Hyponatremia c. Hypocalcemia d. Hypotonic fluid loss e. Hypertonic fluid loss

b. Hyponatremia c. Hypocalcemia Because of the osmotic pressure of sodium, water will be excreted with the sodium lost with the diuretic. A change in the relative concentration of sodium will not be seen, but an isotonic fluid loss will occur. Diuretics can also cause a loss of calcium in the urine.

While caring for an 84-year-old patient, the nurse monitors the patient's fluid and electrolyte balance, recognizing what as a normal change of aging? a. Hyperkalemia b. Hyponatremia c. Decreased insensible fluid loss d. Increased plasma oncotic pressures

b. Hyponatremia A decrease in renin and aldosterone and an increase in ADH and atrial natriuretic peptide (ANP) lead to decreased sodium reabsorption and increased water retention by the kidney, both of which lead to hyponatremia. Loss of subcutaneous tissue and thinning dermis of aging lead to increased moisture lost through the skin. Plasma oncotic pressure is often decreased because of lack of protein intake.

With which disorder is hyperkalemia often associated? a. Hypoglycemia b. Metabolic acidosis c. Respiratory alkalosis d. Decreased urine potassium levels

b. Metabolic acidosis In metabolic acidosis, hydrogen ions in the blood are taken into the cell in exchange for potassium ions as a means of buffering excess acids. This results in an increase in serum potassium until the kidneys have time to excrete the excess potassium

What is an example of an appropriate IV solution to treat an extracellular fluid volume deficit? a. D5W b. 3% saline c. Lactated Ringer's solution d. D5W in 1⁄2 normal saline (0.45%)

c. Lactated Ringer's solution An isotonic solution does not change the osmolality of the blood and does not cause fluid shifts between the ECF and ICF. In the case of ECF loss, an isotonic solution, such as lactated Ringer's solution, is ideal because it stays in the extracellular compartment. A hypertonic solution would pull fluid from the cells into the ECF, resulting in cellular fluid loss and possible vascular overload.

A patient who has a large amount of carbon dioxide in the blood also has what in the blood? a. Large amount of carbonic acid and low hydrogen ion concentration b. Small amount of carbonic acid and low hydrogen ion concentration c. Large amount of carbonic acid and high hydrogen ion concentration d. Small amount of carbonic acid and high hydrogen ion concentration

c. Large amount of carbonic acid and high hydrogen ion concentration The amount of CO2 in the blood directly relates to carbonic acid concentration and subsequently hydrogen ion concentration. The CO2 combines with water in the blood to form carbonic acid and in cases in which CO2 is retained in the blood, acidosis occurs.

Priority Decision: On assessment of a central venous access device (CVAD) site, the nurse notes that the transparent dressing is loose along 2 sides. What should the nurse do immediately? a. Wait and change the dressing when it is due. b. Tape the 2 loose sides down and document. c. Apply a gauze dressing over the transparent dressing and tape securely. d. Remove the dressing and apply a new transparent dressing using sterile technique.

d. Remove the dressing and apply a new transparent dressing using sterile technique. The greatest risk with central venous access device (CVAD) is systemic infection. Dressings that are loose should be changed at once to reduce this risk.