Nursing 403 Ch 13
A client weighing 160 pounds (72.6 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?
A loss of 0.5 kg, or 1 lb, represents a fluid loss of about 500 mL. Therefore, a loss of 1,000 mL would be equivalent to the loss of 2 lbs
Which condition leads to chronic respiratory acidosis in older adults? - Decreased renal function - Erratic meal patterns - Thoracic skeletal change - Overuse of sodium bicarbonate
Correct response: Thoracic skeletal change Explanation: Poor respiratory exchange as the result of chronic lung disease, inactivity, or thoracic skeletal changes may lead to chronic respiratory acidosis. Decreased renal function in older adults can cause an inability to concentrate urine and is usually associated with fluid and electrolyte imbalance. A poor appetite, erratic meal patterns, inability to prepare nutritious meals, or financial circumstances may influence nutritional status, resulting in imbalances of electrolytes. Overuse of sodium bicarbonate may lead to metabolic alkalosis.
A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the nurse's best answer? - passive osmosis - free flow - passive elimination - active transport
Correct response: active transport Explanation: Active transport is the physiologic pump that moves fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate for energy. Passive osmosis does not require energy for transport. Free flow is transport of water naturally. Passive elimination is a filter process carried out in the kidneys.
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?
Respiratory alkalosis Explanation: Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.
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? - 110 mEq/L - 130 mEq/L - 145 mEq/L - 165 mEq/L
Correct response: 165 mEq/L Explanation: The normal sodium level is 135- 145 mEq/L (135-145 mmol/L). In hypernatremia, the serum sodium level exceeds 145 mEq/L (145 mmol/L) and the serum osmolality exceeds 300 mOsm/kg (300 mmol/L). 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). Body temperature may increase mildly, but it returns to normal after the hypernatremia is corrected.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? - Low heart rate - Elevated blood pressure - Rapid respiration - Subnormal temperature
Correct response: Elevated blood pressure Explanation: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? - No effect - Increases arterial pH - Decreases arterial pH - Provides long-term pH regulation
Correct response: Increases arterial pH Explanation: Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.
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. - Monitor for signs and symptoms of dehydration. - Teach the client about increased fluid intake. - Assess the client's weight daily for trends.
Correct response: Provide oral care every 2-3 hours. Explanation: Providing oral care for the client every 2-3 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.
Which is the most common cause of symptomatic hypomagnesemia? - Intravenous drug use - Alcoholism - Sedentary lifestyle - Burns
Correct response: Alcoholism Explanation: Alcoholism is currently the most common cause of symptomatic hypomagnesemia. Intravenous drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia.
A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply. - Blood urea nitrogen (BUN) of 23 mg/dL - Serum osmolality of 310 mOsm/kg - Serum sodium of 148 mEq/L - Serum glucose of 90 mg/dL - Urine specific gravity of 1.03 - Hematocrit level of 48%
Correct response: Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Urine specific gravity of 1.03 Explanation: Severe dehydration is associated with an increased BUN (N = 10 to 20 mg/dL), serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L) and urine specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would also be elevated but are within normal range for this question.
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? - Confusion - Headache - Nausea - Hallucinations
Correct response: Confusion Explanation: Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.
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? - Continue to monitor client with another appointment. - Be prepared to administer a lactated Ringer's IV. - Be prepared to administer a sodium chloride IV. - Consider sodium restriction with discontinuation of salt tablets.
Correct response: Consider sodium restriction with discontinuation of salt tablets. Explanation: The client's symptoms of feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy suggest hypernatremia. The client needs to be evaluated with serum blood tests soon; a later appointment will delay treatment. It is necessary to restrict sodium intake. Salt tablets and a sodium chloride IV will only worsen this condition. A Lactated Ringer's IV is a hypertonic IV and is not used with hypernatremia. A hypotonic solution IV may be a part of the treatment, but not along with the salt tablets.
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 - Respiratory acidosis - Metabolic alkalosis - Respiratory alkalosis
Correct response: Metabolic acidosis Explanation: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
Which electrolyte is a major cation in body fluid? - Chloride - Bicarbonate - Potassium - Phosphate
Correct response: Potassium Explanation: Potassium is a major cation that affects cardiac muscle functioning. Chloride, bicarbonate, and phosphate are anions.
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 137 mEq/L - Potassium level of 3.8 mEq/L - Sodium level of 150 mEq/L - Potassium level of 6 mEq/L
Correct response: Sodium level of 150 mEq/L Explanation: Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? - Specific gravity of 1.02 - Urine pH of 3.0 - Absence of protein - Absence of glucose
Correct response: Urine pH of 3.0 Explanation: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.
The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated. a. 0.9% NaCl b. 5% DW c. 0.45% NS d. 3% NS
Correct response: b. 5% DW Explanation: A solution of D5W is an isotonic IV solution that is contraindicated in head injury because it may increase intracranial pressure.
A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia? - hypervolemia - hypercalcemia - hypomagnesemia - hypermagnesemia
Correct response: hypomagnesemia Explanation: If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.
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? - vital signs - edema - intake and output - weight
Correct response: weight Explanation: Daily weight provides the ability to monitor fluid status. A 2-lb (0.9 kg) weight gain in 24 hours indicates that the client is retaining 1 L of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output do not account for unexplainable fluid loss.
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition?
dehydration Explanation: Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. The most common fluid imbalance in older adults is dehydration. Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from excessive oral intake or rapid IV infusion of fluid. Early signs of hypervolemia are weight gain, elevated BP, and increased breathing effort. Hypercalcemia occurs when the serum calcium level is higher than normal. Some of its signs include tingling in the extremities and the area around the mouth (circumoral paresthesia) and muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the blood. Symptoms include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias.