HURST REVIEW - Fluid and Electrolytes

isotonic solutions

go into the vascular space and stay there (NS, LR, D5W), ALERT: do not use these solutions in clients w/ HTN, cardiac disease or renal disease

hypotonic solutions

goes into the vascular space and then shifts out into the cells to replace cellular fluid; don't cause HTN (D2.5W, 1/2 NS, 0.33% NS)

hypertonic solutions

high alert; volume expanders that will draw fluid into the vascular space from the cell (D10W, 3% NS, D5LR, D51/2NS, D5NS, TPN, albumin)

dehydration, too much sodium, not enough water

hypernatremia =

dilution, too much water, not enough sodium

hyponatremia=

inverse

sodium and potassium relationship

increases

what happens to aldosterone when blood levels get low?

pituitary gland

where is ADH found?

adrenal glands

where is aldosterone found?

vasopressin

ADH- may be used as an ADH replacement in diabetes insipidus

Bradycardia, tall and peaked T waves, prolonged PR intervals, flat or absent P waves, and widened QRS, conduction blocks, and ventricular fibrillation

EKG changes with hyperkalemia

U waves, PVCs, and ventricular tachycardia

EKG changes with hypokalemia

third spacing

When fluid goes to a place that does you no good. Examples: burns and ascites.

2,3,5,6 Rationale 2., 3., 5., & 6 Correct: Causes of fluid volume deficit (hypovolemia) include loss of fluid from anywhere as well as third spacing of fluid that occurs with such things as burns. Burns can result in fluid loss from the burn area as well as the third spacing, which increases the risk for hypovolemia and shock. As the fluid volume decreases, the BP and CVP both decrease. Remember, less volume, less pressure. Also, when the fluid volume becomes depleted, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. You will see the urine specific gravity increase because the small amount of urine being produced will be very concentrated. 1. Incorrect: The client with a severe burn will lose fluids from the burn area and will also third space fluid to a place that does them no good. Therefore, they will go into a fluid volume deficit, not a fluid volume excess. 4. Incorrect: When the fluid volume becomes depleted, such as what occurs with burns, the urine output will decrease in an effort to hold on to the fluid (compensate) or the kidneys are not being perfused. Go to pages 4-5 of your student book if you missed this question.

A client is admitted following a severe burn. What changes related to fluid status would the nurse anticipate? 1. Fluid volume excess 2. Hypovolemia 3. Third spacing 4. Increased urine output 5. Low CVP 6. Increased urine specific gravity

4 Rationale 4. Correct: Diabetes insipidus is a condition that results from decreased ADH production. Therefore, the client will be diuresing large volumes of water which leads to a fluid volume deficit. We worry about shock in these clients. Keep in mind that concentrated makes #s go up and dilute makes #s go down in reference to specific gravity, sodium, and hematocrit. Here, the urine is very dilute which means the urine specific gravity will be low. 1. Incorrect: As the client loses volume through the kidneys, the blood (serum) will become very concentrated. Therefore, you would expect the hematocrit to be high, not low. 2. Incorrect: Don't let the name diabetes insipidus trick you into thinking it affects the glucose level. It is an ADH problem, not a glucose problem. We are worried about fluid volume deficit here. 3. Incorrect: You do not expect to see protein in the urine in DI. In fact, protein is not seen in the urine unless there is a kidney problem. This is an ADH problem, not a kidney problem. You are worried about a large amount of water loss with this client. If you missed this question, review the content again on page 2 of your student book.

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? 1. Low serum hematocrit 2. High serum glucose 3. High urine protein 4. Low urine specific gravity

1 Rationale 1. Correct: The client's potassium level is low. Spironolactone is a potassium sparing diuretic which would cause the potassium to be retained. 2. Incorrect: Furosemide is a potassium depleting diuretic which would further deplete the potassium level. 3. Incorrect: Bumetanide is a potassium depleting diuretic which would further deplete the potassium level. 4. Incorrect: Hydrochlorothiazide also leads to potassium loss, which would further deplete the potassium level. Go to page 3 of your student book if you missed this question.

A client is admitted to the cardiac floor in heart failure. The lung sounds reveal crackles bilaterally, and the BP is 160/98. The client has been on diuretics at home and the potassium level is 3.3 mEq/L (3.3 mmol/L). Which diuretic would the nurse anticipate being prescribed for this client to minimize potassium loss? 1. Spironolactone 2. Furosemide 3. Bumetanide 4. Hydrochlorothiazide

1,3,4 Rationale 1., 3., & 4. Correct: Since this client has hypocalcemia, PO Calcium replacement would be an appropriate treatment. Now, let's look at the others that are not as obvious. Vitamin D helps to improve calcium absorption, which will help increase the calcium levels. So, what is sevelamer hydrochloride and how will this help hypocalcemia? Well, it is a phosphate binder. And remember that we said if you bind the phosphorus, the phosphorus levels go down. And since phosphorus and calcium have inverse relationships, as the phosphorus levels go down, the calcium levels will go up! 2. Incorrect: IV Calcium should be administered slowly or by slow infusion and the client should always be on a heart monitor. If you give calcium too rapidly by IV, the client may have vasodilation, hypotension bradycardia, cardiac arrhythmias, syncope, and cardiac arrest. Don't forget to be watching for the widening of the QRS complex when administering IV calcium! 5. Incorrect: Phosphate supplements would cause the calcium to be even lower in this client. Remember, phosphorus and calcium have an inverse relationship. We would give phosphate binders, not supplements. Go to page 9 of your student book if you missed this question.

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? 1. PO Calcium 2. Rapid IV Push Calcium 3. Vitamin D 4. Sevelamer hydrochloride 5. Phosphate supplements

2 Rationale 2. Correct: Did you recognize that the sodium level of 149 is too high? The normal sodium level is 135-145 mEq/L (135-145 mmol/L). Think about the testing strategy that we mentioned to you. Look for neuro changes when the sodium level is not within normal limits. The brain does not like it when the sodium level is messed up. So, performing a neurological assessment on this client would be important. 1. Incorrect: What type of fluid is 3% NS? It's a hypertonic solution that contains a lot of sodium! That would be a killer answer here because this client's sodium level is already too high! 3. Incorrect: The sodium level is too high. The nurse would have the client to decrease, not increase, the oral intake of sodium. 4. Incorrect. With hypernatremia, there is too much sodium and not enough fluid. Therefore, you would want this client to increase, not decrease, the fluid intake to dilute the sodium level in the blood. Go to page 10 of your student book if you missed this question.

A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mEq/L (149 mmol/L). What action by the nurse would be most appropriate at this time? 1. Administer 3% NS at 150 mL/hr 2. Perform neurological assessment 3. Increase oral intake of sodium 4. Decrease fluid intake

3 Rationale 3. Correct: First, you need to recall that potassium is excreted by the kidneys. If the kidneys are not working well, the serum potassium will go up! You always monitor the urinary output before and during IV potassium administration. Since the urine output has decreased below 30 mL/hr, we know that the urinary output is not adequate. Therefore, the client could start retaining too much potassium. The priority action would be to stop the infusion and then follow this action by notifying the healthcare provider. 1. Incorrect: You may have picked up on the decreased output and thought that you could increase PO fluid intake to increase output. However, the priority action would be to first stop the potassium infusion until the urinary output is adequate. This is a safety issue. 2. Incorrect: We do not want to administer any more potassium to this client. The urine output is not adequate and the client could be retaining too much potassium. 4. Incorrect: Polystyrene sulfonate (Kayexalate®) is used as a treatment for clients with known hyperkalemia. We are trying to prevent this client from becoming hyperkalemic by stopping the IV potassium infusion as the urine output has decreased. Go to pages 11-12 of your student book if you missed this question.

A client was admitted with reports of prolonged diarrhea. The client's admission potassium level was 3.3 mEq/L (3.3 mmol/L) and is receiving an IV of D5 ½ NS with 20 mEq KCL at 125 mL/hr. The UAP reports an 8 hour urinary output of 200 mL. The previous 8 hour urinary output was 250 ml. What should be the nurse's priority action? 1. Encourage the client to increase PO fluid intake. 2. Administer a supplemental PO dose of potassium. 3. Stop the IV potassium infusion. 4. Administer polystyrene sulfonate PO

1 Rationale 1. Correct: Albumin is a hypertonic solution. This type of solution will draw fluid from the cell into the vascular space. This builds up the volume in the vascular space. Therefore, the nurse must watch for fluid volume excess. Hypertonic solutions are used in clients who have 3rd spacing, severe edema, or ascites. 2. Incorrect: Since hypertonic solutions, such as albumin, pull fluid from the cell into the vascular space, we would worry about cellular dehydration and shrinkage, not cellular edema. 3. Incorrect: As the fluid is pulled from the cells into the vascular space, you would expect to see an increase in the BP as the volume in the vascular space increases. You know... more volume, more pressure! We would be watching for hypertension, not hypotension. 4. Incorrect: Think about what we said about the BP when considering the CVP. Since the volume in the vascular space increases with hypertonic solutions, you would also expect the CVP to increase as well. We have to watch closely to make sure that we do not start seeing signs that we are overloading the heart when administering hypertonic solutions. So we will watch this client carefully for an increasing CVP. Go to page 7 of your student book if you missed this question.

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client? 1. Fluid volume excess 2. Cellular edema 3. Severe hypotension 4. Decreasing CVP

2 Rationale 2. Correct: Cushing's is a disease that results in increased secretion of aldosterone. Having too much aldosterone causes the client to be at risk for fluid volume excess (FVE) due to the increased retention of both sodium and water. 1. Incorrect: Cushing's is a problem associated with an increased production of aldosterone, not ADH. The client will be retaining both sodium and water. 3. Incorrect: The client would not be losing excess fluid as is seen in clients with Diabetes Insipidus (DI), an ADH problem. The client will be retaining both sodium and water due to the increased aldosterone and would be at risk for fluid volume excess. 4. Incorrect: Increased thyroxine levels is related to hyperthyroidism, not Cushing's disease. This client has a problem with too much aldosterone and a resulting FVE. If you missed this question, go back and study page 1 in your student book.

A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would best indicate understanding of the teaching? 1. "The increased level of ADH will cause my potassium level to be too high." 2. "I will be retaining sodium and water due to the increased amount of aldosterone." 3. "I will be losing lots of fluid due to the hormonal imbalance I have." 4. "I will feel jittery and nervous due to the elevated thyroxine levels."

2,4,5 Rationale 2., 4., & 5. Correct: Think about fluid volume excess and heart failure. Things such as effervescent soluble medications and canned/processed foods should be avoided because they all contain a lot of sodium which increases fluid retention. Therefore, the chicken noodle soup and the cold cut deli-ham sandwiches should be avoided. 1. Incorrect: Fresh fish is a good, healthy selection that is low in sodium, which is what this client needs. Make sure to avoid smoked or cured fish/meats because these would have a higher sodium content. 3. Incorrect: Salt, as a seasoning, should be avoided because this would increase the fluid retention problem. However, a good alternative to salt for seasoning foods is to use lemon, lemon juice, and pepper. These are lower in sodium than salt. If you missed this question, go to page 1 of your student book to review.

The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? Select all that apply: 1. Broiled, fresh fish 2. Effervescent soluble medications 3. Seasoning with lemon pepper 4. Chicken noodle soup 5. Deli-ham sandwiches

2,4,5 Rationale 2., 4., & 5 Correct: As you learned, magnesium acts like a sedative. Since we know that magnesium can cause respiratory depression, the nurse should always have a baseline respiratory assessment prior to initiating an infusion of magnesium. Muscle tone and DTRs can also become depressed, so a baseline assessment of DTRs would be very important. How is magnesium excreted? That's right! Through the kidneys. The nurse should always assess kidney function and urinary output prior to and during IV magnesium administration because of the risk of magnesium toxicity if it is being retained. 1. Incorrect: Magnesium administration does not impair liver function, so although the alcoholic client may have altered liver function, this is not an assessment that the nurse would be most concerned about related to magnesium administration. In fact, hypomagnesemia is a common problem in alcoholics which may require increasing foods high in magnesium or magnesium supplementation by PO or IV routes. 3. Incorrect: Magnesium levels are not influenced by calcium levels, so this is not an assessment that would be a priority for the nurse at this time. Go to page 9 of your student book if you missed this question.

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? 1. Liver function 2. Respiratory rate 3. Calcium levels 4. Deep Tendon Reflexes (DTRs) 5. Urinary output

inversely related

calcium and phosphate relationship

ca gluconate

what is the antidote for mg toxicity?

heart problem

what should you think of first with fluid retention?