Prep U chapter 40, Nursing Fluid & Electrolyte prep u, Chapter 4 - PrepU - Fluid and Electrolyte and Acid-Base Imbalances, Taylor's Chapter 39: Fluid, Electrolyte, and Acid-Base balance (PrepU), Prep-U Chapter 13: Fluid and Electrolytes: Balance and...

A client with emphysema is at a greater risk for developing which of the following acid-base imbalances?

Chronic respiratory acidosis

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? • 30 gtt/min • 50 gtt/min • 20 gtt/min • 40 gtt/min

Correct response: • 50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

The nurse is instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium? • Salad • Cauliflower • Cheese • Meat

Correct response: • Cheese Explanation: Dairy products are excellent sources of calcium.

A nurse is caring for four different pediatric clients all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot? • Infant • School-aged child • Preschool-aged child • Toddler

Correct response: • Infant Explanation: The foot is a potential IV insertion site for neonates and infants, but it should not be used once a child can walk.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? • Remove the IV from the site and start at another location. • Immediately notify the primary care provider. • Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. • Aspirate the catheter and attempt to flush again.

Correct response: • Remove the IV from the site and start at another location. Explanation: If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

Which client will have more adipose tissue and less fluid? a) A man b) A child c) A woman d) An infant

Correct response: A woman Explanation: Women have a lower fluid content because they have more adipose tissue then men.

What is the lab test commonly used in the assessment and treatment of acid-base balance? a) Urinalysis b) Arterial blood gas c) Complete blood count d) Chemistry I

Correct response: Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood focusing on the red and white blood cells. The urinalysis assesses the components of the urine

A decrease in arterial blood pressure will result in the release of a) Thrombus b) Insulin c) Renin d) Protein

Correct response: Renin Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release

A patient who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor?

Decreased blood volume and intracellular dehydration

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. Which of the following would the nurse expect to find when assessing the client's gastrointestinal system?

Diarrhea

Causes of dehydration

Diarrhea, vomiting, sweating, diabetes, frequent urination, burns, fever

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which of the following actions should the nurse perform to avoid further complications and provide relief to the client?

Discontinue the IV

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which of the following actions should the nurse perform to avoid further complications and provide relief to the client?

Discontinue the IV promptly

A client with hypertension is treated with a diuretic. The client complains of muscle weakness and falls easily. The nurse should assess which electrolyte?

Diuretics, given for high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes - POTASSIUM, calcium, and magnesium

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Supplemental potassium should not be added to the client's intake

______ and ______ are at increased risk for dehydration.

Elderly and infants

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?

Every 72 hours

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea

When an elderly client receiving a blood transfusion with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing

Fluid overload - occur when blood components are infused too quickly or too voluminously

Hypovolemia

Fluid volume deficit

Hypervolemia

Fluid volume excess

Mr. Smith is admitted to your unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is which of the following?

Fluid volume excess

A dialysis unit nurse caring for a patient with renal failure will expect the patient to exhibit which fluid and electrolyte imbalances?

Fluid volume excess and acidosis The kidneys are also responsible for acidbase balance, and in the presence of renal failure, the kidneys cannot regulate hydrogen ions and bicarbonate ions, so the patient develops metabolic acidosis.

The process of filtration begins at the

Glomerulus

***Metabolic alkalosis

H+ deficit/HCO3-excess

***Metabolic acidosis

H+ excess/HCO3-deficit

***Metabolic

HCO3- change with pH

Causes of Hypovolemic shock

Hemmorhage, trauma, spontaneous coronary artery dissection, uterine rupture, ectopic pregnancies, ulcers, burns

When an 80-year-old client who takes diuretics for management of hypertension informs the nurse she take laxatives daily to promote bowel movements, the nurse assesses the client for possible symptoms of

Hypokalemia

What type of solution has a LOWER osmolarity than plasma?

Hypotonic Will cause fluids to move OUT of the intravascular space RATHER THAN pull fluids from tissues into the vascular space

A patient with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this patient's needs?

Implanted CVADs - ideal for long-term uses such as chemotherapy

Thyroid Gland

Increases blood flow in the body by releasing thyroxine, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output.

A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe?

Infiltration

A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe?

Infiltration - escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall - swelling, pallor, coldness, or pain around infusion site & decrease in flow rate

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which of the following fluid compartments?

Intracellular

What stimulates our thirst mechanism?

Intracellular dehydration and decreased blood volume

What organ regulates the production of BICARBONATE?

Kidneys

What size needle use for a large bolus IV catheter?

LARGE 18 gauge +

A nurse is caring for a patient who has burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this patient?

Lactated Ringer's solution is a roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43-). It is used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea and in treating mild metabolic acidosis.

A nurse is caring for a patient who has burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this patient?

Lactated Ringer's solution, it is used in treatment of burns, and fluid lost as bile or diarrhea

Solvents

Liquids that hold a substance in a solution

A child accidentally consumes a container of wood alcohol. The ED physician knows that the child is at risk of developing which of the following?

Metabolic acidosis

A 75-year-old client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which of the following acid-base imbalances?

Metabolic alkalosis

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Metabolic alkalosis

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?

Metabolic alkalosis

The client with a small bowel obstruction has a nasogastric tube to low, continuous suction. The nurse explains that this treatment places the client at risk for which of the following?

Metabolic alkalosis

Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L. For what manifestations will you be alert?

Muscle weakness, fatigue, and dysrhythmias

When educating a client about foods that affect fluid balance, the nurse would advise the client to decrease:

Na+ Sodium (Na+) is the most abundant electrolyte in the extracellular fluid (ECF). Na+ regulates extracellular fluid volume; Na+ loss or gain is accompanied by a loss or gain of water. Potassium (K+) is the major intracellular electrolyte. Calcium (Ca++) is a major component of bones and teeth. Magnesium (Mg++) is the most abundant intracellular cation after potassium.

What do the lungs help maintain in homeostasis?

O2, CO2, acid/base.

Acid-Base Imbalances

Occur when carbonic acid or bicarbonate levels become disproportionate in ECF

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently.

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

Offer the client sugar-free candy to help combat thirst. Explanation: To minimize thirst for clients on fluid restriction, offer sugar-free candy and gum to help minimize thirst.

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

Potassium Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

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

Pulse

S/Sx of hypovolemic shock

Rapid, weak pulse, elevated but shallow R, mottled to gray skin, weak, tired, oliguria (decreased urine output), decreased BP, cool skin, confusion/change in mental status

Total Body Water (or Fluid)

Refers to the total amount of water, which is approximately 50% - 60% of body weight in a healthy person.

A decrease in arterial blood will result in the release of

Renin

Capillary Filtration

Results from the force of blood "pushing" against the walls of the capillaries. At the arterial end of hte capillaries, filtration is dependent primarily on arterial blood pressure; at the venular side of the capillaries, filtration is dependent on venous blood pressure. - The "pushing" force is HYDROSTATIC PRESSURE - The "pulling" force is COLLOID OSMOTIC PRESSURE (or ONCOTIC pressure) - Capillary filtration occurs along the first half of hte vessel and reabsorption occurs along the second half. - Filtration pressure is the difference between colloid osmotic pressure and blood hydrostatic pressure.

Major Electrolytes in ECF

Sodium, chloride, calcium and bicarbonate

A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse?

Spinach Sardines, whole grains, and green leafy vegetables also provide calcium.

Mr Powell, a dehydrated 35 year old has intravenous fluid running at 250 cc/h. for rapid rehydration. He is complaining of burning at the site. You see no redness, swelling, heat, or coolness upon inspection. You suspect

That the fluid is infusing too rapidly for comfort

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which of the following interventions should the nurse perform for this client?

The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion

The nurse is caring for a patient who had a parathyroidectomy. Upon evaluation of the patient's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances

A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?

The pump will continue to infuse fluid even when the needle is displaced

A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?

The pump will continue to infuse fluid even when the needle is displaced.

How does our body regulate fluids?

The thirst mechanism located in the hypothalamus

A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unitwith signs and symptoms of hypovolemia—minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?

Third-spacing

How does body fluid move through the body?

Through intracelluar and extracellular (intravascular and interstitial fluid)

A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation?

Tingling or twitching sensation in the fingers

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as a) Cellular hydration b) Total parenteral nutrition c) Blood transfusion therapy d) Volume expander

Total parenteral nutrition Explanation: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as

Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as

Total parenteral nutrition - 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.

Function of Fluids

Transport nutrients, wastes, hormones, blood cells. Cellular metabolism Electrolyte Solvent Help maintain a normal body temp Assists with digestion and elimination Tissue lubricant

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?

Urine pH of 3.0

VTBI

Volume To Be Infused

What do we give a patient who is dehydrated?

a hypotonic solution to get the fluid to the tissues

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

what is a buffer

a substance that prevents body fluids from becoming overly acidic or alkaline.

Over hydration

above normal amounts of water in extracellular spaces

What does the GI tract help maintain in homeostasis?

absorbs water and nutrients, eliminates waste

the patients fluid intake should include the following

all fluid and foods that are liquid at room temperature, agency's containers, sips of water count, all parenteral fluid, subcutaneous fluids, gastrointestinal tube feeding, iv flushes

What does the Thyroid gland help maintain in homeostasis?

all metabolic events.

What is active transport used by?

amino acids, glucose in kidneys and intestine, sodium ions, potassium ions, hydrogen ions, and calcium ions.

what does bicarbonate do in the body and value

body's primary buffer system value- 25-29 mEq/L

what is the phosphate buffer system

buffer system in intracellular fluid (converts weak bases to acid in the kidneys)

what is the carbonic acid-sodium bicarbonate buffer system

buffer system is balance of most common acid and most common base in human body (20:1 bicarbonate to carbonic acid ratio) most important buffer system (buffers as much as 90% of hydrogen in extracellular fluid)

what is the protein buffer system?

buffer system is mixture of plasma and globing in hemoglobin of red blood cells. assist in minimizing changes in pH and outside of the cell.

What does the cardiovascular system help maintain in homeostasis?

carries all resources.

S/Sx of hyponatremia

cell swelling, hypotension, edema, muscle cramps, weakness, dry skin Severe: increased ICP, lethargy, focal weakenss, seizures, death

When providing care for a patient who has a peripheral intravenous catheter in situ

change the site every 3 to 4 days

what is third-space shift

distributional shift of body fluid into potential body spaces (plural, peritoneal, or pericardial spaces; joint cavities; the bowel) and the fluid becomes trapped in the body space

Third-space fluid shift

distributional shift of body fluids into potential body spaces

What happens with too much hypotonic solutions?

edema

The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply.

facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?

febrile reaction - because of the recipient's hypersensitivity to the donor's white blood cells

Explain what will happen to cells if a hypotonic solution is administered?

fluid goes from the intravascular to intestinal causing the cell to swell

what happens when using a hypertonic solution

fluid is drawn out of the cell into the hypertonic solution to create a balance (the cell shrinks)

S/Sx of Hypochloremia

hyperexcitability of muscles, tetany, hyperactive DTR, weakness, muscle cramps

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? isotonic hypotonic hypertonic plasma

hypertonic Explanation: Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? hypertonic solution colloid solution isotonic solution hypotonic solution

hypertonic solution Explanation: Hypertonic solutions are used in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. Hypotonic solutions are administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. However, these solutions are not related to clients with cerebral edema.

The nurse is caring for Mrs. Roberts, an 86-year-old patient, who fell at home and was not found for two days. Mrs. Roberts is severely dehydrated. The nurse is aware that elderly people are at increased risk for fluid imbalance for which of the following reasons?

increase in fat cells, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults

what does an ADH hormone do

increase in response to issue that increase blood osmolarity (more concentrated), cause fluid or blood loss, or cause a decrease in circulating blood volume

Arterial blood gases reveal that a patient's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

increased respiratory rate - hyperventilation results in increased CO exhalation and increase pH, the goal is 7.35 to 7.45

What happens to vascular volume in a hypertonic solution?

increases

what does the thyroid gland do?

increases the blood flow in the body and increases renal circulation

What does an increase in WBC mean?

infection

what causes hypervolemia

malfunction of kidneys, failure of heart to pump (CHF)

what is sensible losses

measurable such as urination, liquid in stool, and wounds

What can not occur if the Ph is not between 7.35-7.45?

metabolic function

what does magnesium do in the body and value

metabolism of carbohydrates and proteins, vital actions involving enzymes values- 1.3-2.3 mEq/L

why is daily weights important

most accurate indicator of fluid volume status when performed daily at same time. encourage patients with fluid volume imbalances to continue at home

Interstitial-to-plasma shift

movement of fluid from space surrounding cells to blood

anions

negatively charged ions

S/sx of hypocalcemia

numbness, tingling of fingers, mouth or feet; tetany; muscle cramps; seizures

***Acidosis

pH below 7.35

what are the ranges in a pH scale

pH scale- 1-14 neutral pH level- 7 acid- 1-6.9 base-7.1-14)

The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis?

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L

S/sx of hyperkalemia

paralysis, cardiac arrest

what is filtration

passage of fluid through a permeable membrane from the area of higher to lower pressure.

what puts you at risk for imbalances

pathophysiology (acute and chronic illness- asthma, CHF, dialysis patients), abnormal losses of body fluid, older adults and young children, exposure to elements, burns, trauma, surgery

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? platelets granulocytes albumin cryoprecipitate

platelets

cations

positively charged ions

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure Explanation: Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease.

A client has a physician's order for NPO following abdominal surgery. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy to

replace fluid and electrolytes

Active transport

requires energy for movement of substances through the cell membrane (moves with the gradient but needs energy to do this)

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? (Select all that apply.)

respiratory muscle weakness confusion ventricular dysrhythmia Fluid volume deficit causes a low BP (100/48 mm Hg), poor skin turgor, and an elevated heart rate (128/bpm). Fluid excess can cause crackles and distended neck veins.

A nurse is assessing for the presence of edema in a client who is confined to bed after fracturing her femur. The nurse would pay particular attention to which area?

sacral when determining the presence of edema. Edema is most noticeable in dependent areas of the body. When the client is sitting or standing, the edema can be assessed in the legs. The edema cannot be assessed in the hands and abdomen, as these are not dependent areas

what is an isotonic solution

same concentration of particles as plasma (275-295 mOsm/L), no fluid shift occurs bc of equal concentration. we are just wanting to rehydrate them. fluid remains in intravascular compartment

The passageways of the kidney permit the urine to flow to the bladder and:

selectively reabsorb or secrete substance to maintain fluids and electrolytes.

Risk factors for Hypovolemic Shock

severe trauma or burns

S/Sx of Hyperchloremia

tachypnea, weakness, lethargy, diminished cognitive ability, hypertension, decreased cardiac output, dysrhythmia, coma

what is diffusion

tendency of solutes to move freely throughout a solvent (coasting downhill) the solute moves from an area of higher concentration to an area of lower concentration

s/sx of hyperphosphatemia

tetany, anorexia, nausea, muscle weakness, tachycardia

how does potassium help with the acid base balance during acidosis

the body protects itself from the acidic state by moving hydrogen ions into the cells. Therefore, potassium moves out to make room for hydrogen ions and the potassium level increase

what is osmosis

water passes from an area of lesser solute concentration to greater concentration until equilibrium is established

When do Fluid imbalances occur?

when the body's compensatory mechanisms are unable to maintain a homeostatic state

The student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells." Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate?

"Granulocytes are a type of white blood cell that can help fight infection."

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?

"I received a blood transfusion in the United Kingdom."

what is colloid osmotic pressure?

"pulling force" force exerted by proteins in the bloodstream that tends to pull water into vessels.

what is hydrostatic pressure?

"pushing pressure" force exerted by fluid/water in blood vessels pushing fluid and solutes OUT of the vessel.

Hematocrit is what?

% of RBC in plasma

A client has been diagnosed with metabolic acidosis. What assessment finding does the nurse expect?

*Decreased pH below 7.35* Rationale: In metabolic acidosis, the client's pH will decrease below 7.35 or normal range. In addition , the client's HC03- will decrease to below 22 mEq/L.

Fluid Output

- 2,500 - 2,900 mL per day - 1,500 mL from urine - 600 mL from sweat - 300 mL from breathing - 200 mL from feces

Average Daily Fluid Intake

- 2,600 mL per day - 1,300 mL comes from ingested water - 1,000 mL comes from ingested food - 300 mL comes from metabolic oxidation

Extracellular Fluid (ECF)

- All the fluid OUTSIDE the cells - 30% of total body water - 20% of the adult's body weight - EXCLUDES the intravascular + interstitial compartments

Hypertonic

- Has a GREATER osmolarity than plasma (>295 mOsm/L) - Because it has a GREATER oslmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to SHRINK.

KVO

- Keep Vein Open - Run infusion 30 mL/hr

Nonelectrolytes

- Molecules in the body that remain intact WITHOUT a charge - Urea + glucose

Parathyroid Glands

- Regulate calcium + phosphate balance by means of partthyroid hormone (PTH). PTH influences bone REABSORPTION, calcium absorption from the intestines and calcium reabsorption from the renal tubes.

Ringers LActate (Lactated Ringers)

- Sodium chloride, sodium lactate, potassium chloride and potassium lactate.

TKO

- To Keep Open (same as Keep Vein Open) - Run infusion 30 mL/hr

A client with emphysema is at a greater risk for developing which acid-base imbalance? 1- chronic respiratory acidosis 2- metabolic alkalosis 3- metabolic acidosis 4- respiratory alkalosis

1

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? 1- Metabolic acidosis 2- Respiratory acidosis 3- Metabolic alkalosis 4- Respiratory alkalosis

1

Specific gravity of urine

1.005-1.030

what are some examples of a hypertonic solution

1.5%, 3%, or 5% sodium chloride, D5NS or D5LR, D10W

***Sodium levels

135 - 145 mEq/L

Normal Serum Values: SODIUM

135 - 145 mEq/L

Below which serum sodium level may convulsions or coma can occur?

135 mEq/L

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? 1- Tetanic contractions 2- Jugular vein distention 3- Weight loss 4- Polyuria

2

client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? 1- Lactated Ringer solution 2- 0.45% NaCl 3- 0.9% NaCl 4- 5% NaCl

2

***Phosphorus levels

2.5 - 4.5 mg/dL

Normal Serum Values: PHOSPHATE

2.5 - 4.5 mg/dL

****Normal HCO3 levels

22-26 mEq/L

***Bicarbonate levels

25 - 29 mEq/L

what is the osmolarity for the blood

275-295 mOsm/L

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of:

280 mOsm/kg.

You are doing an admission assessment on an elderly patient newly admitted for end-stage liver disease. You must assess the patient's skin turgor. What should you remember when evaluating skin turgor? 1- Overhydration causes the skin to tent. 2- Dehydration causes the skin to appear edematous and spongy. 3- Inelastic skin turgor is a normal part of aging. 4- Normal skin turgor is moist and boggy.

3

Your client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap? 1- Metabolic acidosis 2- Respiratory alkalosis 3- Metabolic alkalosis 4- Respiratory acidosis

3

Dehydration is considered a loss of ________% of body weight

3% or more

***Potassium levels

3.5 - 5.0 mEq/L

Which of the following fluids should be administered slowly to prevent circulatory overload?

5% NaCl

Which of the following fluids should be administered slowly to prevent circulatory overload?

5% NaCl When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% (NaCl) and 5% saline (NaCl).

At what 2 levels of pH does DEATH occur?

6.8 pH 7.8 pH

What is the standard drop factor of microdrip tubing?

60 drops/mL Explanation: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL)

what is the pH level of blood

7.35-7.45; the blood is slightly alkaline

***Calcium serum levels

8.6 - 10.2 mEq/L ionized 4.5 - 5.1

What percentage of potassium that is excreted daily, leaves the body by way of the kidneys?

80

What happens to our thirst mechanism as we age?

>60 our sense of thirst weakens and are kidneys are unable to conserve water as well

The nurse is caring for a client with an acid base imbalance. Which of these does the nurse recognize is correct regarding compensation?

A pH moves toward the normal range

Trousseau's Sign

A test for latent TETANY in which carpal spasm is induced by inflating a sphygmomanometer cuff on the upper arm to a pressure exceeding systolic blood pressure for 3 minutes. A positive test may be seen in hypoCALEMIA and hypoMAGNESMIA

Which client will have more adipose tissue and less fluid?

A woman p.1417

Gastrointestinal tract

Absorbs water + nutrients that enter the body via this rougt

Edema

Accumulation of fluid in the INTERSTITIAL space

How does body fat affect your body fluid?

Adipose tissue holds less water

Ion

An atom or molecule carrying an electrical charge. CATION are positive charges + ANIONS are negative charges.

The nurse is caring for a client who has excessive diarrhea. Which of these acid base disturbances does the nurse anticipate uncovering during evaluation of the arterial blood gas?

An increase in bicarbonate

Which patient is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

An infant has considerably more total-body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits

ADH

Antidiuretic hormone

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?

Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV.

A nurse is changing a peripheral venous access dressing for a patient. Which of the following is a recommended step in this procedure?

Apply chlorhexidine using a back and forth friction scrub for at least 30 seconds.

A nurse flushing a capped peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation?

Aspirate and attempt to flush the line again.

A client is placed on bedrest. Which of the following factors will occur?

Bedrest will cause a breakdown of bone and an increase in serum calcium

How are body fluids distributed?

Body fluids are distributed throughout the body. In a healthy adult, body fluids are 50-60% of the body weight in a health person.

Which of the following are the insensible mechanisms of fluid loss?

Breathing

The nurse caring for a client with respiratory acidosis examines arterial blood gas (ABG) results. Which change from the initial value indicates the client's respiratory acidosis is improving?

COs has decreased

The nurse recognizes the role of the lungs in acid-base balance is regulation of which of the following?

CO₂

A nursing instructor is discussing administration of total parenteral nutrition (TPN) with a nursing student. Which statement by the student would require further teaching?

"I will be sure to change the TPN tubing every other day."

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?

"I've been taking antacids almost every 2 hours over the past several days." Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit. V or nasogastric suction diarrhea = metabolic acidosis

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

"Let me refer you to the blood bank so they can provide you with information."

The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply.

"The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." The adrenal glands regulate blood volume by secreting aldosterone." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." The heart and blood vessels react to hypovolemia by stimulating fluid retention rather than the kidneys.

A client who is receiving total parenteral nutrition and lipids asks the nurse why the solution looks like milk. What is the most appropriate nursing response?

"The white milky solution contains lipids or fat to provide extra calories." A parenteral lipid emulsion is a mixture of water and fats in the form of soybean or safflower oil, egg yolk phospholipids, and glycerin. Lipid solutions, which look milky white, are given intermittently with TPN solutions. They provide additional calories and promote adequate blood levels of fatty acids. Lipids cannot be mixed with TPN, as the lipid molecules tend to break or separate

The nurse is teaching a nursing student how to record strict I&O;for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." Explanation: Fluid output is the sum of liquid eliminated from the body, including urine, emesis (vomitus), blood loss, diarrhea, wound or tube drainage, and aspirated irrigations. In cases in which an accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, diapers, or dressings, and subtracts the weight of a similar dry item. An estimate of fluid loss is based on the equivalent: 1 lb (0.47 kg) = 1 pint (475 mL)

what are examples of cations

(+ charge) sodium, potassium, calcium, hydrogen, and magnesium ions

what are examples of anions

(- charge) chloride, bicarbonate, and phosphate ions

what is hypomagnesemia

(<1.5) caused by nasogastric suctioning, alcohol withdrawal, admin of tube feeding, sepsis, or burns

What is hypophosphatemia?

(<1.8) caused by alcohol withdrawal, diabetic ketoacidosis, hyperventilation, insulin release, diuretics, or administration of calories to malnourished patient

what is hyponatremia

(<135) caused by loss of sodium through vomiting, diarrhea, fistulas, sweating, or diuretics

what is hypokalemia

(<3.5) caused by vomiting, gastric suctioning, alkalosis, diarrhea, or diuretics

what is hypocalcemia

(<8.9) caused by inadequate calcium intake, impaired calcium absorption, or excessive calcium loss

what is hypochloremia

(<96) caused by severe vomiting, drainage of gastric fluid, metabolic alkalosis, diuretic therapy, and burns

what is hypercalcemia

(>10.2) caused by cancer and hyperparathyroidism

what is hyperchloremia

(>106) caused by metabolic acidosis, head trauma, increased perspiration, and decreased glomerular

what is hypernatremia

(>145) caused by excessive water loss or excess sodium through fluid deprivation, decreased fluid consumption, diarrhea, hyperventilation, or burns

what is hypermagnesemia

(>2.5) caused by renal failure or excessive use of magnesium-containing antacids/laxatives

what is hyperphosphatemia

(>2/6) caused by impaired kidney excretion and hypoparathyroidism

what is hyperkalemia

(>5) caused by renal failure, medication use (potassium chloride)

To calculate the H2CO3 content of the blood, the nurse needs to measure the Pco2 (partial pressure of CO2) by its solubility coefficient. What is the solubility coefficient of CO2?

*0.03* Rationale: The H2CO3 content of the blood can be calculated by multiplying the partial pressure of CO2 (Pco2) by its solubility coefficient, which is 0.03.

The nurse is providing care for several clients on a medical unit. Which client likely has the highest risk for developing an acid-base imbalance?

*A client who is being treated for acute kidney injury and who requires dialysis* Rationale: Because of the key role that the kidneys play in the maintenance of acid-base balance, individuals with kidney disease are vulnerable to acid-base disorders. Anaphylaxis, syphilis and fistulas do not present particular risks for acid-base imbalances.

Which is the primary mechanism for transporting carbon dioxide (CO2) in the body?

*As bicarbonate in the plasma* Carbon dioxide (CO2), the byproduct of metabolism, is transported in three ways: as a dissolved gas, as bicarbonate (HCO3-), and attached to hemoglobin with a reversible bond as carbaminohemoglobin. The primary transport method is in the form of bicarbonate in the plasma.

An older adult has had a "sour stomach" and has treated it at home by taking frequent doses of baking soda (sodium bicarbonate). What nursing action is most appropriate?

*Assess the client for signs and symptoms of hypokalemia* Rationale: Ingestion of sodium bicarbonate causes metabolic alkalosis with a consequent risk of hypokalemia. Fomepizole is an antidote to ethylene glycol poisoning and metabolic acidosis. A hypertonic intravenous solution would not resolve the client's acid-base imbalance.

A client has been admitted to the intensive care unit after recovering from cardiogenic shock. In the hours since admission, the client's arterial blood gases indicate acidosis, most likely acute lactic acidosis. Which signs, symptoms, and diagnostic findings might his care team anticipate before acid--base balance is restored?

*Dysrhythmias* Rationale: As with any form of acidosis, pH is apt to be lower than normal. Metabolic acidosis is also associated with dysrhythmias, decreased alertness, and nausea and vomiting. Respiration is likely to be increased in both rate and depth.

Respiratory alkalosis can be caused by a respiratory rate in excess of that which maintains normal plasma Pco2 levels. What is a common cause of respiratory alkalosis?

*Hyperventilation* Rationale: One of the most common causes of respiratory alkalosis is hyperventilation, which is characterized by episodes of over breathing, often associated with anxiety.

The nurse is reviewing the following lab results of a client diagnosed with renal failure: pH: 7.24 PCO2: 38 mm Hg HCO3:18 mEq/L The nurse would interpret this as:

*Metabolic acidosis* Rationale: Metabolic acidosis would be diagnosed based on the findings related to a low pH level (<7.3) and a low bicarbonate level. Respiratory acidosis represents a decreased pH and an increased PCO2, metabolic alkalosis represents an increased pH and a increased HCO3, and respiratory alkalosis represents an increased pH and a decreased PCO2.

The student is studying buffer systems. Which of the following is the largest buffer system in the body?

*Proteins* Rationale: Proteins are the largest buffer system in the body

A client's arterial blood gases include the following: pH: 7.29 HCO3-: 18 mmol/L PCO2: 36 mm Hg PO2: 94 mm Hg What response by the nurse is the most appropriate?

*Replace fluids and electrolytes as ordered.* Rationale: The client's low pH and HCO3- coupled with normal oxygen and carbon dioxide levels are suggestive of metabolic acidosis. Fluid and electrolyte replacement is necessary, but a hypertonic solution would not be used.

A patient with acquired immune deficiency anemia is taking several medications to control the disease. Which of the following medications taken by the patient is the nurse concerned may be causing the patient's severe lactic acidosis?

*Zidovudine (AZT)* A variety of drugs can produce life-threatening lactic acidosis by inhibiting mitochondrial function. These drugs include the biguanide antidiabetic drugs (metformin) and the antiretroviral nucleoside reverse transcriptase inhibitors (zidovudine [AZT]).

The nurse is caring for a client with acute primary respiratory acidosis. When determining the cause of the acidosis the nurse is aware that which of these is most common?

*a) Impaired alveolar ventilation* b) Renal bicarbonate retention c) Increased metabolic acids d) Decreased CO2 retention Rationale: Acute respiratory acidosis is frequently caused by impaired alveolar ventilation with CO2 retention. Increased metabolic acids, such as lactic acid, are characteristic of metabolic acidosis. Bicarbonate retention is a compensatory response to respiratory acidosis, or it can be the cause of metabolic alkalosis when retention is excessive.

The nurse is caring for a client who has excessive diarrhea. Which of these acid base disturbances does the nurse anticipate uncovering during evaluation of the arterial blood gas?

*a) Metabolic acidosis* b) No change in values from normal c) Increased pH value d) An increase in bicarbonate Rationale: The client who has diarrhea has increased loss of bicarbonate from the intestinal tract, which results in metabolic acidosis. The other answers are incorrect. The pH value would be decreased, and the bicarbonate would be decreased.

Which conditions place clients at risk for respiratory acidosis? Select all that apply.

*a) Morbid obesity* *b) Kyphoscoliosis* c) Diabetes mellitus *d) Drug overdose* *e) Pneumonia* Rationale: Respiratory acidosis is caused by conditions that suppress respirations or impair alveolar ventilation. These include drug overdose, head injury, lung diseases such as asthma, emphysema, chronic bronchitis, pneumonia, pulmonary edema and respiratory distress syndrome. Airway obstruction also causes respiratory acidosis. This could be caused by chest injury, kyphoscoliosis (spinal curvature), extreme obesity, or treatment with paralytic medications.

The nurse is reviewing the medication administration record (MAR) of a client with metabolic acidosis. Which medications in the MAR could contribute to the metabolic acidosis? Select all that apply.

*a) Zidovudine (AZT)* b) Captopril (Capoten) *c) Metformin (Glucophage)* *d) Acetylsalicylic acid (Bufferin)* e) Amoxicillin (Amoxil) Rationale: A number of medications inhibit mitochondrial function which can lead to lactic acidosis as a cause of metabolic acidosis. These include biguanide oral antidiabetic agents such as metformin (Glucophage); antiretroviral nucleoside reverse transcriptase inhibitors (NRTIs), and medications such as zidovudine (AZT) used to treat HIV/AIDS. Aspirin toxicity can also lead to acidosis.

The nurse caring for a client with respiratory alkalosis examines arterial blood gas (ABG) results. Which change from the initial value indicates the client's respiratory alkalosis is improving?

*pH has decreased* Rationale: In respiratory alkalosis, the client has a net loss of carbon dioxide (CO2) which creates a rise in pH. The pH needs to move away from alkalosis, which is the high end of the pH scale, for the client's condition to demonstrate improvement. To lower the pH, either the carbon dioxide (CO2) level needs to increase or the bicarbonate level needs to decrease.

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. - "Try to drink at least six to eight glasses of water each day." - "Try to limit your fluid intake to 1 quart of water daily." - "Limit sugar, salt, and alcohol in your diet." - "Report side effects of medications you are taking, especially diarrhea." - "Temporarily increase foods containing caffeine for their diuretic effect." - "Weigh yourself daily and report any changes in your weight."

- "Try to drink at least six to eight glasses of water each day." - "Limit sugar, salt, and alcohol in your diet." - "Report side effects of medications you are taking, especially diarrhea." - "Weigh yourself daily and report any changes in your weight." In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

Phosphate Buffer System

- 1 of 3 buffer systems - Active in INTRACELLULAR fluids, especially renal tubules - Converts the alkaline sodium phosphate (a weak base) to acid-sodium phosphate in the kidneys

Carbonic Acid-Sodium Bicarbonate Buffer System

- 1 of 3 buffer systems - Carbonic acid is the most common acid in body fluid - Bicarbonate is the most common base in body fluid - Normal ECF has a 20 parts bicarbonate to 1 part carbonic acid. If the 20:1 ratio is off then a change in pH occurs - Buffers 90% of H+ in ECF - Lungs assist by regulating the PRODUCTION of carbonic acid (results from combination of carbon dioxide and water) - Kidneys assist the bicarbonate system by REGULATING the production of bicarbonate.

Protein Buffer System

- 1 of 3 buffer systems - Mixture of plasma proteins and the globin portions of hemoglobin in red blood cells - Minimize changes in pH

Isotonic

- A solution that has about the SAME concentration of particles (OSMOLARITY) as plasma (275 - 295 mOsm/L) - Remains in the intravascular compartment WITHOUT any net flow across the semipermeable membrane

Buffer + 3 Buffer System

- A substance that prevents body fluids from becoming overly acidic or alkaline - Combine with excess acids or bases to prevent major changes in pH - Either bind or release hydrogen atoms - Keep pH of body fluids as close as possible to 7.35=7.45 3 Buffer Systems 1.) Carbonic Acid-Sodium Bicarbonate Buffer System 2.) Phosphate Buffer System 3.) Protein Buffer System

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? - Encourage foods and fluids with high sodium content. - Administer oral K supplements as ordered. - Caution the patient about eating foods high in potassium content. - Discuss calcium-losing aspects of nicotine and alcohol use.

- Administer oral K supplements as ordered. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

Extracellular Fluid (ECF)

- All the fluid OUTSIDE the cells - 30% of total body water - 20% of the adult's body weight - EXCLUDES the intravascular + interstitial compartmentsu

Fluid Volume Excess (FVE)

- Also called HYPERVOLEMIA - Caused by malfunction of the kidneys and heart failure (results in excess fluid in lungs) - Due to the increaed extracellular osmotic pressure from the retained sodium and water, fluid is pulled form the cells to equalize the tonicity. By the time the intracellular and extracellular spaces are isotonic to each other, an excess of both water and sodium is in the ECF, whereas the cells are nearly depleted. - Excessive ECF may occur in the intravascular or interstitial spaces - Accumulation of fluid in the interstitial space is known as EDEMA

Bicarbonate (HCO-)

- An ion that is the major chemical BASE BUFFER within the body - Found in both ECF + ICF - Regulates acid-base balance - Losses possible via diarrhea, diuretics and early renal insufficiency - Excess possible via overingestion of acid neutralizers, such as sodium bicarbonate - Bicarbonate levels regulated primarily by the kidneys - Bicarbonate readily available as a result of carbon dioxide formation during metabolism

Fluid Volume Deficit (FVD)

- Caused by a loss of BOTH water + solutes in the same proportion from the ECF space CALLED a HYPOVOLEMIA (or isotonic fluid loss) - Both osmotic and hydrostatic pressure changes force the interstitial fluid into the intravascular space i an effort to compensate for the loss of volume in the blood vessels - As the interstitial space is depleted, its fluid becomes hypertonic + cellular fluid is then drawn into the insterstitial space, leaving cells WITHOUT adequate fluid to function properly. - FVD results from the loss of body fluids, especially if fluid intake is decreased - Young children, older adults and people who are ill especially at risk for hypovolemia

Sodium (Na+)

- Chief electrolyte of ECF - Normal serum level is 135-145 mEq/L - Regulates extracellular fluid volume - Na+ loss or gain = loss or gain of water - Affects serum osmolarity - role in muslce contraction + transmission of nerve impulses - Regulation of acid-base balance as sodium bicarbonate - ENTERS the body through gastrointestinal tract from dietary sources - EXITS the body though gastrointestinal tract, kidneys and skin - TRANSPORTED out of the cell by the SODIUM-POTASSIUM PUMP - REGULATED by RENIN-ANGIOTENSIN-ALDERSTRONE system - Elimination and reabsorption regulated by kidneys - Sodium concentrations affected by salt and water intake

Hypochloremia + Hyperchloremia

- Chloride deficit and excess - Hypo chloride DEFICIT - Hyper chloride EXCESS - Hypochloremia < 69 mEq/L - Hyperchloremia >106 mEq/L - Hypochloremia can result from severe vomiting and diarrhea, drainage of gastric fluid (GI) tube, metabolic alkalosis, diauretic therapy and burns. - Hypochloremia may result in hyperexcitiability of muscles, tetany, weakness and muscle cramps - Hyperchloremia can result from metabolic acidosis, head trauma, increased perspiration, excess adrenocortical hormone production, decreased glomerular filtration - Hyperchloremia signs and symptoms include: tachypenea, weakness, lethargy, diminished cognitive ability, hypertension, decreased cardiac output, dysrhythemias and comas.

Heart + Blood Vessels

- Circulate nutrients + water throughout body - Circulate blood though the kidneys under sufficient pressure for urine to form (pumping action of the heart) - React to hypovolemia by stimulating fluid retention (stretch receptors in the atria + blood vessels)

Alkalosis

- Deficit HYDROGEN atoms - pH above 7.45

Intervenous Solutions

- Dextrose (D) - Water (W) - Saline (S) - Dextrose 5% in water (DsW) - Normal saline 0.9% NaCl (NS or NaCl) ---- 0.45% NaCl ---- 0.25% NaCl

• A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? • Place the client in the Trendelenburg position to keep the client's airway open. • Notify the primary care provider immediately for possible fluid overload. • Notify the primary care provider immediately because these are signs of speed shock. • Check all clamps on the tubing and check tubing for any kinking.

Correct response: • Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify the primary care provider immediately because the client may be exhibiting signs of fluid overload. The Trendelenburg position is not used to rectify this complication, but to help raise the blood pressure of a client with hypotension.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? - Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. - Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. - Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. - Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

- Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

Increased secretion of PTH causes?

- Elevated serum CALCIUM concentration - Elevated serum PHOSPHATE concentration

Acidosis

- Excess HYDROGEN atoms - pH below 7.35

Brawny Edema

- Fluid can no longer be displaced secondary to excessive interstitial fluid accumulation - NO pitting - Tissue palpates as firm or hard - Skin surface shiny, warm or moist

Hypotonic

- Has LESS osmolarity than plasma (<295 mOsm/L). - A hypotonic solution in the intravascular space moves OUT of the intravascular space and INTO intracellular fluid, causing cells to SWELL + possiably BURST.

Nervous System

- Inhibits and stimulates mechanisms influencing fluid balance; acts chiefly to regulate sodium and water intake and excretion - Regulates oral intake by sensing intracellular dehydration, which triggers thirst (thirst center located in the hypothalamus) - Neurons, calls osmoreceptors, are sensitive to changes in the concentration of ECF, sending appropriate impulses to the pituitary gland to release ADH or hibit its release to maintain ECF volume concentration.

Major Anions

- Ions that hold a negative charge - Chloride, bicarbonate and phosphate

Major Cations

- Ions that hold a positive charge - Sodium, potassium, calcium, hydrogen and magnesium

• The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? • AB negative • A positive • O negative • B positive

Correct response: • O negative Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. Rh-negative persons should never receive Rh-positive blood

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? - Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. - Keeping fluids readily available for the patient. - Emphasizing the long-term outcome of increasing fluids when the patient returns home. - Planning to offer most daily fluids in the evening.

- Keeping fluids readily available for the patient. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

Decreased secretion of PTH causes?

- Lowered serum CALCIUM concentration - Lowered serum PHOSPHATE concentration

Hypomagnesemia + Hypermagnesemia

- MAGNESIUM deficit or excess - Hypo magnesium DEFICIT <1.5 mEq/L - Hyper magnesium EXCESS >2.5 mEq/L - Hypomagnesemia may occur with nasogastric suction, diarrhea, withdraw from alchohol, administration of tube feedings, parenternal nutrition sepsis or burns. - Hypomagnesia results in muscle weakness, tremors, tetany, seizures, heart block, change in mental status, hyperactive tendon reflexes and respiratory paralysis - Hypermagnesemia occurs when renal failure or excessive magnesium intake (with antacids or laxatives). - Hypermagnesia results in nausea, vomiting, weakness, flushing, lethargy, respiratory depression, coma and cardiac arrest.

Calcium (Ca+)

- MOST ABUNDANT electrolyte in the body - 99% of body calcium is stored in bone - 1% inside cells - 0.1% in ECF - Normal serum levels 8.6 - 10.2 mg/dL - Regulated by Parathyroid hormone + calcitonin - Role in blood coagulation and in transmission of nerve impulses - Helps regulate muscle contraction and relaxation - Activates enzymes that stimulate essential chemical reactions in the body - Absorbed from foods in the presence of normal gastric acidity and vitamin D - Lost via feces and urine - Primarily excreted by gastrointestinal tract; lesser extend by kidneys - High serum phosphate results in decreased serum calcium level; low serum phosphate leads to increased serum calcium

Chloride (Cl-)

- Major ECF anion - Normal serum value 97 - 107 mEq/L ("911") - Major component of interstitial + lymph fluid; gastric and pancreatic juices, sweat, bile + saliva - Acts with socium to maintain osmotic pressure - Role in the body's acid-base balance; combines with hydrogen ions to produce hydrochloric acid - Enters via gastrointestinal tract - Almost all comes from salt - Normally paired with sodium ; excreted and conserved with sodium by the kidneys - Regulated by aldosterone alongside sodium - Low potassium level leads to low chloride level

Phosphate (PO-)

- Major ICF anion - A BUFFER anion in both ICF and ECF - Role in acid-base balance as a hydrogen buffer - Regulated by parathyroid hormone - ACTIVATED by VITAMIN D - Promotes energy storage - Promotes carbohydrate, protein and fat metabolism - Bone + teeth formation - Regulation of hormone + coenzme activity - Role in muscle + red blood cell function - Enters body via gastrointestinal tract - Sources include all animal products - Absorption is diminished by concurrent ingestion of calcium, magnesium + aluminum - Eliminated by kidneys - Phosphate + calcium are inversely proportional; an increase in one results in a decrease in the other

Potassium (K+)

- Major cation of ICF - Normal serum is 3.5-5.0 mEq/L - Controls intracellular osmolarity - Regulator of cellular enzyme activity - Role in the transmission of electrical impulses in nerve, heart, skeletal, intestinal and lung tissue - Role in protein and carbohydrate metabolism - Role in cellular building - Leading sources

mEq

- Miliequivalent - 1 mEq = 1mg Hydrogen - 1 mEq of any cation is = to 1 mEq of any anion - Total cations are normally = number of total anions, maintaining homeostasis

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? - A pinched and drawn facial expression - Deep, rapid respirations. - Moist crackles heard upon auscultation - Tachycardia

- Moist crackles heard upon auscultation Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

Hypokalcemia + Hyperkalcemia

- POTASSIUM deficit or excess - HYPO potassium DEFICT <3.5 mEq/L - HYPER potassium EXCESS >5 mEq/L - Hypokalcemia may result from: vomiting, gastric suction, alkalosis, diarrhea or as a result of use of diauretics - When ECF potassium falls, potassium moves form the cell, creating an intracellular potassium deficiency. Sodium + hydrogen ions are then retained by the cells to maintain isotonic fluids. - Skeletal muscles are generally the first to demonstrate potassium deficiency. Signs include: muscle weakness, leg cramps, fatigue, paresthesias dysrhythmias - Hyperkalcemia may result from: renal failure, hypoaldosteronism, use of medicaions such as potassium chloride, heparin, angiotensin-converting enzyme (ACE) inhibitors, nonsterodial anti inflammatory drugs (NSAIDs) and potassium sparing diuretics. May result in cardiac arrest if not corrected.

Hypophosphatemia + Hyperphosphatemia

- Phosphorus deficit or excess - Hypo phosphorus DEFICIT - Hyper phosphorus EXCESS - Hypophosphatemia <1.8 mEq/L - Hyperphosphatemia >2.6 mEq/L - Hypophosphatemia can result from alchohol withdraw, diabetic ketoacidosis, hyperventilation, insulin release, absorption problems, and diuretic use. - Signs of hypophosphatemia are: irritability, fatigue, weakness, paresthesias, confusion, seizures and coma - Hyperphosphatemia is commonly caused by impaired kidney excretion and hypoparathyroidism - Hyperhposphatemia can result in tetany, anorexia, nausea, muscle weakness and tachycardia.

Active Transport

- Process that requires energy for the movement of substances though a cell membrane, against the concentration gradient, from an area of lesser solute concentration to an area of higher solute concentration. ATP (Adenosine TriPhosphate) supplies the energy for solute movement into and out of the cell. - Amino acids, glucose, sodium, potassium, hydrogen + calcium - "Pumping Uphill"

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client? • B positive • A positive • O negative • AB negative

Correct response: • O negative Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. B positive, A positive, and AB negative are not considered compatible in this scenario.

A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take? • Continue to use the current intravenous tubing • Tell the client the infusion will be administered later in the shift • Notify the health care provider to request a new prescription for an intravenous infusion • Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing

Correct response: • Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing Explanation: The tubing is contaminated and, if the nurse continues to use the current tubing, the bag's contents will become contaminated during infusion. This action will result in harming the client and can increase the risk of an systemic infection, resulting form poor medical and surgical aseptic techniques.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? • Apply a new dressing and observe for signs of infection over the next several hours. • Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. • Remove the IV catheter and reinsert another in a different location. • Decontaminate the visible portion of the catheter, and then gently reinsert.

Correct response: • Remove the IV catheter and reinsert another in a different location. Explanation: An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the prioritynursing action? • Assess oxygen levels. • Call for assistance. • Stop the transfusion. • Assess for visible rash.

Correct response: • Stop the transfusion. Explanation: Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? - Reposition the extremity and raise the height of the IV pole. - Apply pressure to the dressing on the IV. - Pull the catheter out slightly and reinsert it. - Put on gloves; remove the catheter

- Put on gloves; remove the catheter This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.

Respiratory Regulation of Hydrogen Ions

- Rapid but SHORT TERM regulation of pH, the kidneys are needed for long term regulation - Due to the huge surface area from which CO2 can readily diffuse, the lungs can bring about rapid changes in H+ when needed. - When the amount of CO2 in the blood increases, the sensitive chemorecepors in the respiratory center in the MEDULLA are stimulated to increase the rate and depth of respirations to eliminate more CO2. - As more CO2 is exhaled, blood pH becomes more ALKALINE - When the blood level of CO2 decreases, the respiratory center decreases the rate + depth of respirations to retain the CO2 so that CARBONIC ACID can be FORMED, thereby maintaining balance. - Lungs are the primary controller of CARBONIC ACID supply

Considerations of the Older Adult

- Reduced cardiac, renal and respiratory function - Decreased muscle mass - Multiple medications that can affect cardiac and renal function - Excessive use of laxatives - Decreased thirst response - Dehydration is loss of more than 3% of body weight - Be very careful with fluid replacement measures in older adults due to the risk of fluid overload

Third Space Fluid Shift

- Refers to a distributional shift of body fluids into the transcellular compartment, such as the pleural, peritoneal (ascites), or pericardial areas; joint cavities; the bowel; or an excess accumulation of fluid in the interstitial space - The fluid moves out of the intravascular spaces (plasma) to any of these spaces. Once trapped in these spaces, the fluid is not easily exchanged with ECF. - A deficit in ECF volume occurs - The fluid has NOT been lost but is UNAVAILABLE for use - May be related to a disruption in the colloid osmotic pressure (decreased albumin), increased fluid volume ( excess IV fluid replacement, renal dysfunction), increased capillary hydrostatic pressure (heart failure, hyponaturemia or an increase in the perneability of the capillary membrane (gross tissue trauma) - May occur as a result of a severe burn, bowel obstruction, surgical procedures, pancreatitis, ascites or sepsis.

Adrenal Glands

- Regulate blood volume + sodium and potassium balance by secreting ALDPSTERONE (a mineral corticoid secreted by the adrenal cortex) 1.) The primary regulator of aldosterone appears to be angiotensin II, which is produced by the renin-angiotensin system. A decrease in blood volume triggers this system and increases aldosterone secretion, which causes sodium retention (and thus water retention) and potassium loss 2.) Decreased secretion of aldestrone causes sodium and water loss and potassium retention - Cortisol, another adrenocortical hormone, has only a fraction of the potency of aldosterone - However, secretion of cortisol in large quantities can produce sodium and water retention and potassium deficit

Kidneys

- Regulates extracellular fluid (ECF) VOLUME + OSMOLARITY by selective retention + excretion of body fluids - Regulates electrolyte levels in the ECF by selective retention of needed substances + excretion of unneeded substances - Regulates pH of ECF by EXCRETION or RETENTION of HYDROGEN ions - Excretes metabolic wastes (primarily acids) + toxic substances - Normally filter 180 L of plasma daily in the adult, while excreting only 1.5 L of urine

Lungs

- Remove approximately 300 mL of water daily though exhalation (insensible water loss) in the normal adult - Eliminate about 13,000 mEq of hydrogen ions (H+) daily, as opposed to only 40 to 80 mEq excreted daily by the kidneys - Act promptly to correct metabolic acid-base disturbances; regulate H+ concentration (pH) by controlling the level of carbon dioxide (CO2) in the extracellular fluid as follows: 1.) Metabolic ALKALOSIS causes compensatory hypoventilation, resulting in CO2 RETENTION (increases the acidity of the extracellular fluid) 2.) Metabolic ACIDOSIS causes compensatory hyperventilation, resulting in CO2 EXCRETION (decreases the acidity of the extracellular fluid)

Hyponaturemia + Hyponaturemia

- SODIUM deficit or excess - Hypo is sodium DEFICIT < 135 mEq/L - Hyper is sodium EXCESS > 145 mEq/L - Sodium DEFICIT (hyponaturemia) may occur due to: vomiting, diarrhea, fistuals, sweating or as a result of the use of diuretics - The decrease in sodium causes fluid to move by osmosis from the less concentrated ECF to the ICF space. This shift in fluid leads to a swelling of cells, with resulting confusion, hypotension, edema, muscle cramps and weakness and dry skin. Cerebral edema can lead to seizures and premanent neurologic damage + death. - Sodium EXCESS caused by fluid deprivation, diarrhea, hyperventilation, burns. - In sodium excess, fluids leave the cells because of the increased extracellular osmotic pressure, causing them to shrink and leave the cells without sufficient fluid. May result in signs of neurologic impairment, restlessness, weakness, disorientation, delusion and hallucinations.

Magnesium (Mg+)

- Second most abundant ICF cation after potassium - Normal serum value 1.3 - 2.3 mEq/L - Metabolism of carbohydrates in proteins - Regulated by parathyroid hormone - Activator for many intracellular enzymes - Role in neuromuscular function - Acts on cardiovascular system, producing vasodilation - Enters via gastrointestinal tract - Eliminated by kidneys

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? - Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. - Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. - Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. - Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

- Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

Pituitary Gland

- Stores and relases the antiduretic hormaone (ADH, manufactures in the hypothalamus), which acts to allow the body to retain water. It acts chiefly to regulate sodium and water intake and secretion. Functions of ADH include: 1.) Maintains osmotic pressure of the cells by controlling renal water retention or ecretion a. When osmotic pressure of he ECF is greater than that of the cells (as in hypernaturemia-excess sodium-or hyperglycemia), ADH secretion is increased, causing renal retention of water. b. When osmotic pressure of the ECF is less than that of the cells (as in hyponaturemia), ADH secretion is decreased, cauising renal exretion of water. 2.) Controls blood volume ( less influential than aldosterone) a. When blood volume is decreased, an increased secretion of ADH results in water conseration. b. When blood volume is increased, a decreased secretion of ADH results in water loss

Osmosis

- The MAJOR method of transporting body fluids. - Water shifts and balance depend heavily on this fouth of transport - Water (the solvent) passes from an area of lesser solute concentration and more water to an area of greater solute concentration and less water until equilibrium is established. As a result, the volume of the more concentrated solution increases, and the volume of the weaker solution decreases. It stops when the concentration of solutes has been equalized on both sides of the cell membrane

5 Mechanisms that the Body Uses to Regulate Fluid + Electrolyte Balance

- The body produces balance by shifting fluids and solutes between the ECF and the ICF 1.) Organs + Body Systems 2.) Osmosis 3.) Diffusion 4.) Active Transport 5.) Capillary Filtration

Osmolarity

- The concentration of particles in a solution - Its pulling power

Osmotic Potential

- The elecrolyte's affinity for water - The capacity to pull water into a fluid compartment

Renal Regulation of Hydrogen Ions

- The kidneys excrete or retain hydrogen ions and form or excrete bicarbonate ions of the blood - In ACIDOSIS, the kidneys EXCRETE HYDROGEN IONS and form and CONSERVE BICARBONATE IONS, thus RAISING the pH to return it to a balanced state - The concnetration of BICARBONATE in plasma is REGULATED by the kidneys - Takes longer than lung regulation but is MORE longer lasting - It may take as long as 3 days for a normal fluid pH to be restored by the kidneys

Diffusion

- The tendency of solutes to move freely throughout a solvent - The solute moves from an area of HIGHER concentration to an area of LOWER concentration until EQUILIBRIUM is reached. - Oxygen + carbon dioxide exchange in the lung's alveoli occurs by diffusion

What solutions are used in a hypotonic solution?

-0.45% NaCl (1/2 normal saline) -0.33% NaCl (1/3 normal saline) -D5W, D5NS, D51/2NS

What solutions are used in an isotonic solution?

-0.9% NaCl (normal saline) -Lactated Ringer's

What solutions are used in a hypertonic solution?

-3-5% of NaCl -Dextrose 10% in water -Albumin, hyper alimentation, total parenteral nutrition, pRBCs (packed RBCs)

What do kidneys help maintain in homeostasis?

-Acid/base balance -Fluid and electrolyte balance -Filter waste metabolism -RBC-production -Activate Vitamin D to help with calcium absorption

Hydrostatic pressure

-B/P -pressure that the fluid is going to exert against the cell walls it's contained in

Nursing Dx for Fluid loss

-Deficient fluid volume -Excess Fluid volume -Risk for imbalanced fluid volume -Risk for injury

Renal Mechanism

-Excrete or retain H+ -Excrete or create HCO3-

Major Homeostatic Regulators of Hydrogen Ions (pH) (Buffers)

-Phosphate -Intercellular regulation works within the cell -Protein -In the blood to slightly change shape to hold H+ ions -Potassium -Exchanges for H+ in our cells so we don't get acidic so then K+ will go up

Nursing Interventions for diarrhea

-assess hydration status and v/s -daily weights -moniter i/o (urine and stool) -NO rectal temp -Rehydrates -Collect specimens -Stools for pH and blood -Administer meds as prescribed -Isolation precautions -Skin care -Parent education

Extracellular fluid (ECF)

-fluid outside cells (30%) -includes intravascular and interstitial fluids

Hypertonic

-greater concentration of particles than plasma (cell shrinks) -Pulls fluid from intracellular space into the vascular space

+2 pitting edema

-lasts longer then +1 -fairly normal contour

Hypotonic

-lesser concentration of particles than plasma (cell swells) -Fluid shifts from extracellular space to intracellular

Calcium function in body

-nerve impulse -clotting -muscle contraction -B12 absorption

+1 pitting edema

-normal contour -associated with interstitial fluid volume 30% above normal

Colloid osmotic pressure

-pulls -particles all clumped together so they pull water to try to dilute themselves

+4 pitting edema

-remains for a long time after pressing -frank swelling

+3 pitting edema

-remains several seconds after pressing -skin swelling obvious by general inspection

Isotonic

-same concentration of particles as plasma -Fluid is distributed equally across the intracellular and extracellular spaces.

Which of the following commonly used intravenous solutions is hypotonic?

0.45% NaCl

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be 1- 7.50 2- 7.45 3- 7.35 4- 7.30

1

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting? 1- third-spacing 2- pitting edema 3- anasarca 4- hypovolemia

1

A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypotension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? 1- hypokalemia 2- hyperkalemia 3- hypocalcemia 4- hypercalcemia

1

A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the 1- malignancy is causing the electrolyte imbalance. 2- client's diet is lacking in calcium-rich food products. 3- client may be developing hyperaldosteronism. 4- client has a history of alcohol abuse.

1

A patient with abnormal sodium losses is receiving a regular diet. How can the nurse supplement the patient's diet to provide 1,600 mg of sodium daily? 1- One beef cube and 8 oz of tomato juice 2- Four beef cubes and 8 oz of tomato juice 3- One beef cube and 16 oz of tomato juice 4- One beef cube and 12 oz of tomato juice

1

A patient's most recent arterial blood gases reveal pH = 7.5; HCO3- = 29 mEq/L, and PaCO2 = 51 mm Hg. What health problem could account for these findings? 1- Volume depletion from vomiting 2- Diabetic ketoacidosis (DKA) 3- Atelectasis 4- Hyperventilation

1

Below which serum sodium concentration might convulsions or coma occur? 1- 135 mEq/L (135 mmol/L) 2- 145 mEq/L (145 mmol/L) 3- 140 mEq/L (140 mmol/L) 4- 142 mEq/L (142 mmol/L)

1

It is important for a nurse to know how to calculate the corrected serum calcium level for a patient when hypocalcemia is seen along with low serum albumin levels. Calculate the corrected serum calcium when the serum calcium is 9 mg/dL and the serum albumin is 3 g/dL. 1- 9.8 mg/dL 2- 10.3 mg/dL 3- 11 mg/dL 4- 12 mg/dL

1

The calcium concentration in the blood is regulated by which mechanism? 1- Parathyroid hormone (PTH) 2- Thyroid hormone (TH) 3- Adrenal gland 4- Androgens

1

The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte imbalance? 1- Hypocalcemia 2- Hyperchloremia 3- Hypermagnesemia 4- Hyponatremia

1

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? 1- Magnesium 2- Calcium 3- Phosphorus 4- Potassium

1

The nurse is instructing a client with recurrent hyperkalemia about following a potassium-restricted diet. Which statement by the client indicates the need for additional instruction? 1- "I will not salt my food; instead I'll use salt substitute." 2- "Bananas have a lot of potassium in them; I'll stop buying them." 3- "I'll drink cranberry juice with my breakfast instead of coffee." 4- "I need to check to see whether my cola beverage has potassium in it."

1

The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action? 1- Send the client for a chest x-ray. 2- Administer the prescribed IV fluids. 3- Obtain written consent for the procedure. 4- Assess the client's blood pressure (BP) on the right arm.

1

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? 1- 115 mEq/L 2- 130 mEq/L 3- 145 mEq/L 4- 160 mEq/L

1

The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining? 1- 1 L 2- 500 ml 3- 1500 ml 4- 1250 ml

1

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? 1- Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad 2- Three ounces of sliced ham, beets, and a salad 3- A frozen, packaged low-fat dinner with a side salad 4- Tomato juice, low-fat cottage cheese, and three slices of bacon

1

Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting? 1- pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 2- pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 3- pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 4- pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34

1

Which electrolyte is a major anion in body fluid? 1- Chloride 2- Potassium 3- Sodium 4- Calcium

1

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? 1- Confusion and seizures 2- Sunken eyeballs and spasticity 3- Flaccidity and thirst 4- Tetany and increased blood urea nitrogen (BUN) levels

1

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema? 1- Generalized 2- Dependent 3- Brassy 4- Pitting

1

1 L of Body Fluid = ? lb or ? kg

1 L of Body Fluid = 2.2lb or 1kg

What is the rate of administration for packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia? Select all that apply. 1- Tachypnea 2- Weakness 3- Lethargy 4- Dehydration 5- Hypotension

1,2,3

The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. 1- Compare ABG findings with previous results. 2- Maintain intake and output records. 3- Document presenting signs and symptoms. 4- Administer IV bicarbonate. 5- Suction the client's airway.

1,2,3

To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. 1- pH 2- PaCO2 3- HCO3 4- Glucose 5- Na+ 6- K+

1,2,3

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. 1- Distended neck veins 2- Crackles in the lung fields 3- Shortness of breath 4- Decreased blood pressure 5- Bradycardia

1,2,3

What laboratory findings does the nurse determine are consistent with hypovolemia in a female patient? (Select all that apply.) 1- Hematocrit level of greater than 47% 2- BUN: serum creatinine ratio of greater than 12.1 3- Urine specific gravity of 1.027 4- Urine osmolality of greater than 450 mOsm/kg 5- Urine positive for blood

1,3,4

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply. 1- Drink at least eight glasses of fluid each day. 2- Drink caffeinated beverages to retain fluid. 3- Drink carbonated beverages to help balance fluid volume. 4- Drink water as an inexpensive way to meet fluid needs. 5- Respond to thirst

1,4,5

What two factors stimulate the thirst center?

1.) Dehydration 2.) Low blood volume

3 IV Fluid Administration Routes

1.) Intravenous 2.) 3.) Intraosseous (into bone, often tibia)

2 Ways Fluid is Lost in the Body

1.) Sensible Loss: Can be measured and include urination, defecation + wounds. 2.) Insensible Loss: Cannot be measured or seen and includes sweat and water vapor from lungs during respiration.

***Magnesium levels

1.3 - 2.3 mEq/L

Normal Serum Values: MAGNESIUM

1.3 - 2.3 mEq/L

what are examples of hypotonic solution

1/2 normal saline, 1/3 or 1/4 normal saline, less than 5% dextrose in water, sterile water.

A 42-year-old client has chronic hypo natremia, which requires weekly blood labs to keep him from lapsing into convulsions or a coma. What is the level of serum sodium below which convulsions or coma can occur?

135 mEq/L

Kidneys filter ______ of plasma and excrete ______ of urine

180 L 1.5 L

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? 1- Respiratory alkalosis 2- Metabolic alkalosis 3- Respiratory acidosis 4- Metabolic acidosis

2

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? 1- Lactated Ringer solution 2- 0.45% NaCl 3- 0.9% NaCl 4- 5% NaCl

2

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings? 1- Hypernatremia 2- Hypokalemia 3- Hyperchloremia 4- Hypophosphatemia

2

A client weighing 160 pounds diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the patient loses 1,000 mL of fluid in 24 hours. Choose the weight that would be consistent with this amount of fluid loss. 1- 159 lbs 2- 158 lbs 3- 157 lbs 4- 156 lbs

2

A nurse in the Medical ICU has orders to infuse a hypertonic solution into a patient with low blood pressure. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. What term or terms are associated with this process? 1- Hydrostatic pressure 2- Osmosis and osmolality 3- Diffusion 4- Active transport

2

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? 1- Specific gravity of 1.02 2- Urine pH of 3.0 3- Absence of protein 4- Absence of glucose

2

A patient is admitted with a diagnosis of renal failure. The patient complains of "stomach distress" and describes ingesting several antacid tablets over the past 2 days. Blood pressure is 110/70 mm Hg, face is flushed, and the patient is experiencing generalized weakness. Which is the most likely magnesium level associated with the symptoms the patient is having? 1- 11 mEq/L 2- 5 mEq/L 3- 2 mEq/L 4- 1 mEq/L

2

A patient is diagnosed with SIADH. What disturbance should the nurse be aware of related to this diagnosis? 1- Excess water loss 2- Dilutional hyponatremia 3- Serum sodium level of 148 mg/dL 4- Decreased urine osmolality

2

A patient with a history of poorly controlled type 1 diabetes has begun displaying the characteristic signs and symptoms of diabetic nephropathy. The patient's nurse recognizes that the patient is at risk of disruptions to fluid balance. What role do the kidneys play in the maintenance of normal fluid balance? 1- Secreting or withholding antidiuretic hormone in response to extracellular fluid volume 2- Selectively retaining needed substances and excreting waste products 3- Synthesizing and releasing angiotensin in cases of fluid volume deficit 4- Maintaining the correct concentration of H+ ions in the blood

2

An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? 1- Hyperkalemia 2- Hypokalemia 3- Hypernatremia 4- Hypophosphatemia

2

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? 1- Low heart rate 2- Elevated blood pressure 3- Rapid respiration 4- Subnormal temperature

2

When entering a patient's room, the nurse notices blood clots in the IV line. What is the most appropriate nursing intervention at this time? 1- Milk the tubing. 2- Discontinue the infusion. 3- Irrigate the tubing and catheter. 4- Aspirate the clot from the tubing.

2

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? 1- HCO 21 mEq/L 2- pH 7.48 3- PaCO 36 4- O2 saturation 95%

2

When the postcardiac surgery client demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the client's serum electrolytes, anticipating which abnormality? 1- Hypercalcemia 2- Hyperkalemia 3- Hypomagnesemia 4- Hyponatremia

2

Which could be a potential cause of respiratory acidosis? 1- Vomiting 2- Hypoventilation 3- Diarrhea 3- Hyperventilation

2

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? 1- Administer an ordered decongestant. 2- Instruct the client to breathe into a paper bag. 3- Offer the client fluids frequently. 4- Administer ordered supplemental oxygen.

2

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? 1- Abnormal potassium level 2- Elevated hematocrit level 3- Low white blood count 4- Low urine specific gravity

2

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? 1- Tetanic contractions 2- Jugular vein distention 3- Weight loss 4- Polyuria

2

Which solution is hypotonic? 1- Lactated Ringer solution 2- 0.45% NaCl 3- 0.9% NaCl 4- 5% NaCl

2

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? 1- Hypovolemia 2- Dehydration 3- Hypervolemia 4- Fluid volume excess

2

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply. 1- Crackles on auscultation 2- Cyanosis 3- Hypertension 4- Shoulder pain 5- Dyspnea 6- Tachycardia

2,4,5,6

A nurse is measuring the intake and output of a patient who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?

2,600 mL

over how many days should a nurse look at input and output

2-3 days

2.2lb or 1kg = ? L of Body Fluid

2.2lb or 1kg = 1 L of Body Fluid

Normal Serum Values: BICARBONATE

25 - 29 mEq/L

The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?

25 gtt/min

A 43-year-old patient with a history of alcohol abuse has been admitted to an acute medical unit with complications resulting from liver failure. Upon assessment, the patient's abdomen is distended, firm to touch, and nontender. The nurse recognizes that the patient has excess fluid in his peritoneal space (ascites), a problem that results from the disruption of normal movement of water and electrolytes. What process is primarily responsible for maintaining fluid balance along a concentration gradient? 1- Hydrostatic pressure 2- Active transport 3- Osmosis 4- Filtration

3

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. Na + 130 mEq/L K + 4.6 mEq/L Cl - 94 mEq/L Mg ++ 2.8 mg/dL Ca ++ 13 mg/dL Which of the following alterations is consistent with the client's findings? 1- Hyponatremia 2- Hyperkalemia 3- Hypercalcemia 4- Hypermagnesemia

3

A nurse is analyzing her patient's ABG values. Which result is inconsistent with the diagnosis of respiratory acidosis? 1- pH 7.3 2- PaCO2 50 3- Hyperventilation (PaCO2 25) 4- Hypoventilation (PaCO2 60)

3

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? 1- Metabolic acidosis 2- Metabol 3- Respiratory acidosis 4- Respiratory alkalosisic alkalosis

3

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? 1- The client sees his physician for a check-up yearly. 2- The client has never traveled outside of the country. 3- The client had a liver transplant 2 years ago. 4- The client works in a health care insurance office.

3

A nurse working on a trauma unit is initiating IV fluids for a patient. For what condition would the nurse administer normal saline? 1- Renal impairment 2- Pulmonary edema 3- Burns 4- Heart failure

3

A patient with a diagnosis of thyroid cancer is postoperative day 1 following a total thyroidectomy in which her parathyroid gland was also removed. When assessing for related electrolyte imbalances, what question should the nurse ask the patient? 1- "Do you feel like you're having heart palpitations where your heart feels like it skips a beat?" 2- "How thirsty are you feeling right now?" 3- "Are you feeling any tingling in your hands or around your mouth?" 4- "How would you rate your energy level right now?"

3

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? 1- Sodium level of 137 mEq/L 2- Potassium level of 3.8 mEq/L 3- Sodium level of 150 mEq/L 4- Potassium level of 6 mEq/L

3

A priority nursing intervention for a client with hypervolemia involves which of the following? 1- Establishing I.V. access with a large-bore catheter. 2- Drawing a blood sample for typing and crossmatching. 3- Monitoring respiratory status for signs and symptoms of pulmonary complications. 4- Encouraging the client to consume sodium-free fluids.

3

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? 1- Myasthenia gravis 2- Type 1 diabetes mellitus 3- Extreme anxiety 4- Opioid overdose

3

Hypomagnesemia is a common yet often overlooked imbalance in acutely and critically ill patients. Which of the following patients is most likely at the highest risk of experiencing low serum magnesium levels? 1- An obese male patient who has a history of atherosclerosis and a previous non-ST wave elevation myocardial infarction 2- A patient who is temporarily receiving total parenteral nutrition (TPN) as a result of complications from gastric bypass surgery 3- A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use 4- A teenage patient who is currently being treated for non-Hodgkin's lymphoma (NHL)

3

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? 1- Kidney and liver 2- Heart and lungs 3- Lungs and kidney 4- Pancreas and stomach

3

Which electrolyte is a major cation in body fluid? 1- Chloride 2- Bicarbonate 3- Potassium 4- Phosphate

3

With which condition should the nurse expect that a decrease in serum osmolality will occur? 1- Diabetes insipidus 2- Hyperglycemia 3- Kidney failure 4- Uremia

3

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000 Explanation: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit

Normal Serum Values: POTASSIUM

3.5 - 5 mEq/L

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?

3.5 cm H2O normal pressure is approximately 4 to 11 cm H2O.

A nurse is calculating the output of a client with renal failure and takes into account all fluid loss. What amount would the nurse anticipate as the usual average?

300 to 400 mL/day

***Normal PaCO2 levels

35-45 mmHg

A 22-year-old man with a diagnosis of schizophrenia has been transferred from the psychiatric unit to the medical unit after drinking 5 liters of water over the past hour. Assessment reveals that the patient is oriented to person but not to time or place and that he is drowsy but rousable by touch. When reviewing this patient's most recent blood work, the nurse should pay particular attention to the patient's levels of: 1- Phosphate 2- Calcium 3- Blood urea nitrogen (BUN) 4- Sodium

4

A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/l (145 mmol/L). Should the nurse start salt tablets when caring for this client? 1- Yes, this will correct the sodium deficit. 2- Yes, along with the hypotonic IV. 3- No, start with the sodium chloride IV. 4- No, sodium intake should be restricted.

4

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: 1- metabolic acidosis. 2- metabolic alkalosis. 3- respiratory acidosis. 4- respiratory alkalosis.

4

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? 1- Respiratory acidosis 2- Respiratory alkalosis 3- Metabolic acidosis 4- Metabolic alkalosis

4

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? 1- Respiratory alkalosis 2- Respiratory acidosis 3- Metabolic alkalosis 4- Metabolic acidosis

4

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? 1- Nausea or vomiting 2- Abdominal pain or diarrhea 3- Hallucinations or tinnitus 4- Light-headedness or paresthesia

4

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? 1- Blood pressure 2- Respirations 3- Temperature 4- Pulse

4

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of: 1- 210 mOsm/kg. 2- 230 mOsm/kg. 3- 250 mOsm/kg. 4- 280 mOsm/kg.

4

A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patient's most recent blood work indicates a K+ level of 2.7 mEq/L. This potassium level should prompt the nurse to assess for which of the following physical manifestations? 1- Confusion and decreased level of consciousness 2- Shortness of breath, rales, and peripheral edema 3- Dysphagia, tetany, and emotional lability 4- Fatigue, cramps, and weakness

4

An elderly patient has developed Clostridium difficile-related diarrhea and been subsequently diagnosed with fluid volume deficit (FVD). The nurse providing care for this patient should anticipate: 1- A decreased level of blood urea nitrogen (BUN) 2- An increased level of serum potassium 3- The administration of a hypertonic IV solution 4- The administration of hypotonic or isotonic IV solution

4

An elderly patient has developed Clostridium difficile-related diarrhea and been subsequently diagnosed with fluid volume deficit (FVD). The nurse providing care for this patient should anticipate: 1- A decreased level of blood urea nitrogen (BUN) 2- An increased level of serum potassium 3- The administration of a hypertonic IV solution 4- The administration of hypotonic or isotonic IV solution

4

As part of a large hospital's IV team, two nurses are responsible for inserting peripherally inserted central catheters (PICCs) at the bedside for patients who require this form of venous access. Which of the following patients would most likely require a PICC? 1- A woman who recently suffered a pelvic fracture in a motor vehicle accident 2- An elderly man who has been admitted from the community with a fluid volume deficit 3- A man whose hypocalcemia requires a stat infusion of calcium gluconate 4- A woman who has just been ordered total parenteral nutrition (TPN)

4

Early signs of hypervolemia include 1- a decrease in blood pressure. 2- thirst. 3- moist breath sounds. 4- increased breathing effort and weight gain.

4

Oncotic pressure refers to the 1- number of dissolved particles contained in a unit of fluid. 2- excretion of substances such as glucose through increased urine output. 3- amount of pressure needed to stop the flow of water by osmosis. 4- osmotic pressure exerted by proteins.

4

The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? 1- PaO2 2- PO2 3- Carbonic acid 4- Bicarbonate

4

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH? 1- The lungs are unable to breathe in sufficient oxygen. 2- The lungs are unable to exchange oxygen and carbon dioxide. 3- The lungs have ineffective cilia from years of smoking. 4- The lungs are not able to blow off carbon dioxide.

4

The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status? 1- Vital signs 2- Edema 3- Intake and output 4- Weight

4

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test? 1- Red blood cell count 2- Sputum culture 3- Total hemoglobin 4- Arterial blood gas (ABG) analysis

4

What clinical indication of hyperphosphatemia does the nurse assess in a patient? 1- Bone pain 2- Paresthesia 3- Seizures 4- Tetany

4

What does the nurse expect to see on the ECG reading when serum potassium levels rise to greater than 6 mEq/L? 1- Peaked, widened T waves 2- ST-segment elevation 3- Lengthened QT interval 4- ST-segment depression

4

pH of urine

4.5 - 8.2

normal urine Ph

4.6-8.2

The nurse is calculating the infusion rate for the following order: Infuse 1000 ml of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtts/min. What is the infusion rate?

42 gtts/min When infusing by gravity, divide the total volume in ml (1000 ml) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtts/min

Pitting Edema 2+

4mm pit that last longer than 1+ Fairly normal contour

Hypovolemia can result in a ____% rapid weight loss in adults and a ___% weight loss in infants

5%; 10%

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50 gtt/min

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

Healthy person—total body water is _____% -_____% of body weight

50%-60%

what is a healthy person total water in the body

50%-60%

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O?

55-year old with congestive heart failure on furosemide clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy should be put on I&O

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

60 drops/mL

Normal Serum Values: CALCIUM

8.6 - 10.2 mEq/L

The nurse is calculating an infusion rate for the following order: Infuse 1000 ml of 0.9% Na Cl over 12 hours using an electronic infusion device. What is the infusion rate?

83 ml/hour When calculating the infusion rate with an electronic device, divide the total volume to be infused (1000 ml) by the total amount of time in hours (12). This is 83 ml/hour

***Chloride levels

97 - 107 mEq/L

Normal Serum Values: CHLORIDE

97 - 107 mEq/L

The nurse is caring for the following group of clients. Select the client most likely to be diagnosed with respiratory alkalosis.

A 26-year-old female with anxiety who has been hyperventilating

A nurse is providing care for several clients on an acute medicine unit. Which client should the nurse recognize as being at the highest risk for metabolic alkalosis?

A client on continuous nasogastric suction and whose hypertension is being treated with diuretics

In which client would the nurse be most likely to assess the signs and symptoms of an acid-base imbalance?

A client with chronic obstructive pulmonary disease whose most recent arterial blood gasses reveal a PCO2 of 51 mm Hg

Explain what will happen to cells if a hypertonic solution is administered?

A hypertonic solution has a greater osmolality, causing water to move out of the cells and to be drawn into the intravascular compartment, causing the cell to shrink.

The oncoming nurse is assigned to the following patients. Which patient should the nurse assess first?

A newly admitted 88-year-old with a two-day history of vomiting and loose stools

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?

Acute Confusion related to cerebral edema

A client's most recent laboratory results suggest the presence of metabolic alkalosis. What action by the nurse best addresses a potential cause of this acid-base imbalance?

Administering an antiemetic to treat the client's frequent vomiting

Which age group is at risk for fluid and electrolyte imbalances resulting from fad dieting?

Adolescents

What factors affect normal body fluids?

Age, sex, body fat

A client with dehydration will have an increase in

Aldosterone

Major control over the extracellular concentration of potassium within the human body is exerted by insulin and a) Progesterone b) Testosterone c) Albumin d) Aldosterone

Aldosterone Explanation: Two hormones exert major control over the extracellular concentration of potassium: insulin and aldosterone. Aldosterone enhances renal secretion of potassium.

Major control over the extracellular concentration of potassium within the human body is exerted by insulin and

Aldosterone Two hormones exert major control over the extracellular concentration of potassium: insulin and aldosterone. Aldosterone enhances renal secretion of potassium

Major control over the extracellular concentration of potassium within the human body is exerted by insulin and

Aldosterone - enhances renal secretion of potassium

There are both metabolic and respiratory effects on the acid-base balance in the body. How do metabolic disorders change the pH of the body?

Alter the plasma Hco3- Explanation: Metabolic disorders produce an alteration in the plasma HCO3- concentration and result from the addition or loss of nonvolatile acid or alkali to or from the extracellular fluids. None of the other answers are correct.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Elevate the client's head. Apply a warm compress. Position the client on the left side. Apply antiseptic and a dressing.

Apply a warm compress. Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

What is the lab test used in the assessment and treatment of acid base balance?

Arterial Blood Gas (ABG) - assess acid base balance

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. T

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Arterial blood gas (ABG) analysis

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" Which of the following would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids. p.1446

A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond?

Bicarbonate-carbonic acid buffer system

As other mechanisms prepare to respond to a pH imbalance, immediate buffering is a result of increased:

Bicarbonate/carbonic acid regulation

A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned?

Calcium

The nurse is caring for a patient who had a parathyroidectomy. Upon evaluation of the patient's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

Calcium and phosphorus The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus.

A client has a diagnosis of heart failure, lab results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? Fluid volume excess Pulmonary embolus Cardiac dysrhythmias Tetany

Cardiac dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

Potassium is needed for neural, muscle, and

Cardiac function

A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a) Muscle weakness b) Cardiac irregularities c) Metabolic acidosis d) Increased intracranial pressure (ICP)

Cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias

A patient's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. What signs and symptoms should the nurse vigilantly monitor for?

Cardiac irregularities, hyperkalemia - too much potassium in blood

The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?

Cardiac volume intolerance

Which clients would be appropriate candidates for total parenteral nutrition? Select all that apply.

Client who has second- and third-degree (partial- or full-thickness) burns over 40% of the body Client who had gastric surgery and is unable to eat for a few weeks Client with anorexia nervosa

The nurse is administering albumin to a patient to promote movement of fluid into the capillaries. What is the "pulling force" of fluid by use of a protein such as albumin known as?

Colloid osmotic pressure

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? -hemolytic transfusion reaction: incompatibility of blood product -allergic reaction: allergy to transfused blood -febrile reaction: fever develops during infusion -bacterial reaction: bacteria present in the blood

Correct response: hemolytic transfusion reaction: incompatibility of blood product Explanation: The listed symptoms occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever; hypertension; dry, flushed skin; and abdominal pain occur.

The student nurse asks "What is interstitial fluid?" What is the appropriate nursing response? • "Fluid inside cells." • "Fluid in the tissue space between and around cells." • "Watery plasma, or serum, portion of blood." • "Fluid outside cells."

Correct response: • "Fluid in the tissue space between and around cells." Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? • "I have never given blood before." • "My blood type is B positive." • "I received a blood transfusion in the United Kingdom." • "My spouse would also like to donate blood."

Correct response: • "I received a blood transfusion in the United Kingdom." Explanation: Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? • "Unfortunately, your own blood cannot be reinfused during surgery." • "Let me refer you to the blood bank so they can provide you with information." • "This surgery has a very low chance of hemorrhage, so you will not need blood." • "We now have artificial blood products, so giving your own blood is not necessary."

Correct response: • "Let me refer you to the blood bank so they can provide you with information." Explanation: Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be reinfused.

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? • As fast as the client can tolerate • 200 mL/hr • 75 mL/hr for the first 15 minutes then 200 mL/hr • 1 unit over 2 to 3 hours, no longer than 4 hours,

Correct response: • 1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? • 3,000 • 500 • 1,000 • 3,750

Correct response: • 3,000 Explanation: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtts/min. What is the infusion rate? • 25 gtts/min • 42 gtts/min • 125 gtts/min • 20 gtts/min

Correct response: • 42 gtts/min Explanation: When infusing by gravity, divide the total volume in mL (1,000 mL) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtts/min. The correct answer is 42 gtts/min.

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? • 13 mL/hr • 83 mL/hr • 103 gtts/hr • 100 mL/hr

Correct response: • 83 mL/hr Explanation: When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (8). This is 83 mL/hr. Other options are incorrect.

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? • Pain related to surgical incision • Risk for Infection related to inadequate personal hygiene • Constipation related to immobility • Acute Confusion related to cerebral edema

Correct response: • Acute Confusion related to cerebral edema Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? • Use an alcohol-based mouthwash to moisten your mouth. • Use regular gum and hard candy. • Eat crackers and bread. • Avoid salty or excessively sweet fluids.

Correct response: • Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? • Yogurt • Turkey • Milk • Banana

Correct response: • Banana Explanation: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (32 mmol/L). For what complications should the nurse be aware, related to the potassium level? • Pulmonary embolus • Cardiac dysrhythmias • Fluid volume excess • Tetany

Correct response: • Cardiac dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)? • Removing a client's PICC in anticipation of the client's discharge • Initiating a client's transfusion of packed red blood cells • Changing the dressing on a client's peripheral IV site • Deaccessing a client's implanted port

Correct response: • Changing the dressing on a client's peripheral IV site Explanation: Changing a peripheral IV dressing poses a lower risk to the client's safety than the other listed nursing actions and this would be the safest task to delegate. It would be inappropriate to delegate a blood transfusion, deaccess an implanted port, or remove a PICC to an LPN.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? • Discontinue the IV and relocate it to another site. • Call the primary care provider to see whether anti-inflammatory drugs should be administered. • Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV • Stop the infusion cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.,

Correct response: • Discontinue the IV and relocate it to another site. Explanation: The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action? • Slow the rate of infusion by 50%. • Attempt to aspirate. • Discontinue the IV. • Flush with 3-mL normal saline.

Correct response: • Discontinue the IV. Explanation: Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor. Aspiration is never performed from a peripheral IV. Flushing or slowing the infusion will not alleviate this problem.

• A nurse is caring for a client who has recently suffered burns on 30% of his body. Based on his condition what type of IV solution might be ordered for this client? • 5% dextrose in 0.9% NaCl • Lactated Ringer's • 5% dextrose in 0.45% NaCl • 0.9% NaCl (normal saline)

Correct response: • Lactated Ringer's Explanation: Lactated Ringer's solution is a roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43- ). It is used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea and in treating mild metabolic acidosis.

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: • Kidneys • Lungs • Adrenal glands • Blood vessels

Correct response: • Lungs Explanation: The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? • Muscle weakness, fatigue, and constipation • Nausea, vomiting, and constipation • Muscle weakness, fatigue, and dysrhythmias • Diminished cognitive ability and hypertension

Correct response: • Muscle weakness, fatigue, and dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

as observed the nurse changing a peripheral venous access site dressing is idemonstrating inappropriate technique by implementing which action? • Not preforming the intervention under sterile conditions • Not wearing gloves when preforming the intervention • By pulling the dressing toward the insertion site • By applying stablizing pressure to the catherter

Correct response: • Not wearing gloves when preforming the intervention Explanation: The changing of a peripheral venous access site dressing requires the use of clean gloves to minimize the transmission of microorganisms during the procedure and to prevent the nurse from coming into contact with blood. The intervention does not require sterile precautions. The mammer in which the nurse is applying stablizing pressure to the catherter and pulling the adhered dressing toward the insertion site demonstrates appropriate technique.

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply. • The client will likely develop a fever in the presence of fluid overload. • The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. • A symptom of fluid overload is distended neck veins. • The infusion rate must be carefully monitored during the administration of blood. • Fluid overload is more likely in very young children.

Correct response: • The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. • A symptom of fluid overload is distended neck veins. • Fluid overload is more likely in very young children. • The infusion rate must be carefully monitored during the administration of blood. Explanation: Fluid overload can occur if blood components are infused too quickly or too voluminously. Transfusion-associated circulatory overload is more likely in the very young client or the older adult with poor cardiac or renal function. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds. Circulatory overload can be minimized by infusing packed RBCs (rather than whole blood) and volume-reduced platelets for high-risk clients, then carefully monitoring the infusion rate of blood components.

Potassium is needed for neural, muscle, and: • auditory function. • cardiac function. • skeletal function. • optic function.

Correct response: • cardiac function. Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

Which is a common anion? • potassium • calcium • magnesium • chloride

Correct response: • chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? • increased blood volume and extracellular overhydration • increased blood volume and intracellular dehydration • decreased blood volume and extracellular overhydration • decreased blood volume and intracellular dehydration

Correct response: • decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.

Edema happens when there is which fluid volume imbalance? • water excess • extracellular fluid volume deficit • extracellular fluid volume excess • water deficit

Correct response: • extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space

he nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? • hypertonic • hypotonic, followed by isotonic • hypotonic • isotonic

Correct response: • hypertonic Explanation: A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? • asking if the client is right or left handed • palpating the veins on the nondominant hand • placing the tourniquet on the upper arm for 2 minutes • asking the client to pump their fist several times

Correct response: • placing the tourniquet on the upper arm for 2 minutes Explanation: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.

A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: • replacement of fluids for those lost from vomiting and diarrhea. • an access route to administer medications intravenously. • an access route to replace fluids in combination with blood products. • intravenous fluids to be administered on an outpatient basis.

Correct response: • replacement of fluids for those lost from vomiting and diarrhea. Explanation: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion. Place your answer on the line provided below.

Correct response: 50 gtts/min. Explanation: When administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula:

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. • "Try to drink at least six to eight glasses of water each day." • "Try to limit your fluid intake to 1 quart of water daily." • "Limit sugar, salt, and alcohol in your diet." • "Report side effects of medications you are taking, especially diarrhea." • "Temporarily increase foods containing caffeine for their diuretic effect." • "Weigh yourself daily and report any changes in your weight."

Correct response: • "Try to drink at least six to eight glasses of water each day." • "Limit sugar, salt, and alcohol in your diet." • "Report side effects of medications you are taking, especially diarrhea." • "Weigh yourself daily and report any changes in your weight." Explanation: In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. • 5% dextrose in 0.9% NaCl • 0.9% NaCl (normal saline) • Lactated Ringer's solution • 0.33% NaCl (⅓-strength normal saline) • 0.45% NaCl (½-strength normal saline) • 5% dextrose in Lactated Ringer's solution

Correct response: • 0.33% NaCl (⅓-strength normal saline) • 0.45% NaCl (½-strength normal saline) Explanation: 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? • 1 • 2 • 3 • 4

Correct response: • 2 Explanation: Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? • 1+ pitting edema • 2+ pitting edema • 3+ pitting edema • 4+ pitting edema

Correct response: • 3+ pitting edema Explanation: 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? • Encourage foods and fluids with high sodium content. • Administer oral K supplements as ordered. • Caution the patient about eating foods high in potassium content. • Discuss calcium-losing aspects of nicotine and alcohol use.

Correct response: • Administer oral K supplements as ordered. Explanation: Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? • Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. • Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. • Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. • Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

Correct response: • Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. Explanation: The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? • Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. • Keeping fluids readily available for the patient. • Emphasizing the long-term outcome of increasing fluids when the patient returns home. • Planning to offer most daily fluids in the evening.

Correct response: • Keeping fluids readily available for the patient. Explanation: Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status?' • Recording intake and output. • Testing skin turgor. • Reviewing the complete blood count. • Measuring weight daily.

Correct response: • Measuring weight daily. Explanation: Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? • Respiratory acidosis • Respiratory alkalosis • Metabolic acidosis • Metabolic alkalosis

Correct response: • Metabolic acidosis Explanation: A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? • A pinched and drawn facial expression • Deep, rapid respirations. • Moist crackles heard upon auscultation • Tachycardia

Correct response: • Moist crackles heard upon auscultation Explanation: Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? • Reposition the extremity and raise the height of the IV pole. • Apply pressure to the dressing on the IV. • Pull the catheter out slightly and reinsert it. • Put on gloves; remove the catheter

Correct response: • Put on gloves; remove the catheter Explanation: This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? • Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. • Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. • Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. • Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

Correct response: • Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. Explanation: The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

What is the rate of administration for packed red blood cells? a) 1 unit over 2 to 3 hours, no longer than 4 hours b) IV push over 3 minutes c) As fast as the patient can tolerate d) 200 mL/hr

Correct response: 1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours. Answer A describes platelets, answer C represents cryoprecipitate, and answer D describes fresh-frozen plasma.

The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?

Correct response: 25 Explanation: 150 (mL) x 60 (minutes) / 10 (drop factor) = 25 drops per minute

Which of the following fluids should be administered slowly to prevent circulatory overload? a) 5% NaCl b) 0.9% NaCl c) 0.45% NaCl d) Dextrose 5%

Correct response: 5% NaCl Explanation: When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% (NaCl) and 5% saline (NaCl).

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? a) 40 gtt/min b) 50 gtt/min c) 30 gtt/min d) 20 gtt/min

Correct response: 50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

The oncoming nurse is assigned to the following patients. Which patient should the nurse assess first? a) A newly admitted 88-year-old with a two-day history of vomiting and loose stools b) A 20-year-old, 2 days post-operative open appendectomy who refuses to ambulate today c) A 47-year-old who had a colon resection yesterday and is complaining of pain d) A 60-year-old who is 3 days post-myocardial infarction and has been stable

Correct response: A newly admitted 88-year-old with a two-day history of vomiting and loose stools Explanation: Young children, elderly people, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI patient presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med)

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? a) A peripheral venous catheter inserted to the cephalic vein b) A midline peripheral catheter c) An implanted central venous access device (CVAD) d) A peripheral venous catheter inserted to the antecubital fossa

Correct response: An implanted central venous access device (CVAD) Explanation: Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which of the following interventions should the nurse perform for this complication? a) Elevate the client's head. b) Position the client on the left side. c) Apply a warm compress. d) Apply antiseptic and a dressing.

Correct response: Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? a) Dairy products b) Apricots c) Processed meat d) Bread products

Correct response: Apricots Explanation: Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" Which of the following would the nurse include as a suggestion for this client? a) Use regular gum and hard candy. b) Avoid salty or excessively sweet fluids. c) Eat crackers and bread. d) Use an alcohol-based mouthwash to moisten your mouth.

Correct response: Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, also may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.

Potassium is needed for neural, muscle, and a) Auditory function b) Optic function c) Skeletal function d) Cardiac function

Correct response: Cardiac function Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a) Metabolic acidosis b) Increased intracranial pressure (ICP) c) Cardiac irregularities d) Muscle weakness

Correct response: Cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias.

Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client 's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client? a) Water excess b) Impaired skin integrity c) Risk for injury d) ECF deficient fluid volume

Correct response: ECF deficient fluid volume Explanation: The most appropriate nursing diagnosis is ECF deficient fluid volume deficit because the client has the defining characteristics of the diagnosis. Impaired skin integrity is associated with edema and diarrhea. Risk for injury can occur if electrolyte or fluid imbalances cause postural hypotension, loss of consciousness, or impaired cognition. Water excess is characterized by symptoms like weight gain, headache, and delirium.

A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV? a) Use half-instilled IV solutions before infusing a new one. b) Select a primary tubing of about 37 inches (94 cm) long. c) Avoid replacing IV solution every 24 hours. d) Ensure that the prescribed solution is clear and transparent.

Correct response: Ensure that the prescribed solution is clear and transparent. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What IV complication does this describe? a) Speed shock b) Infiltration c) Thrombus d) Sepsis

Correct response: Infiltration Explanation: Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site, and significant decrease in the flow rate. The signs of sepsis include red and tender insertion site, fever, malaise, and other vital sign changes. The symptoms of thrombus are local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.

A severely malnourished client has been admitted to a health care facility. The nurse is preparing to administer total parenteral nutrition (TPN) to the client. How should the nurse administer the TPN solution? a) It is administered in a peripheral vein with its tip terminating in the jugular vein. b) It is administered in a vein distant from the heart through peripheral veins. c) It is administered in a peripheral vein with its tip terminating in the superior vena cava. d) It is administered in a peripheral vein in a lower limb.

Correct response: It is administered in a peripheral vein with its tip terminating in the superior vena cava. Explanation: TPN solution should be administered through a catheter inserted into the subclavian or jugular vein; the tip terminates in the superior vena cava. Sometimes a peripherally inserted central catheter is used; this long catheter is inserted in a peripheral arm vein but its tip terminates in the superior vena cava as well. Total parenteral nutrition is a hypertonic solution of nutrients designed to meet almost all caloric and nutritional needs. It is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. A TPN solution is not infused in a peripheral vein with its tip terminating in the jugular vein.

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider? a) It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. b) As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 10 mL of fluid remains in the original container. c) The nurse should use new tubing when attaching additional IV solutions. d) Generally, the nurse should change the administration sets of simple IV solutions every 24 hours.

Correct response: It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. Explanation: The nurse's ongoing verification of the IV solution and the infusion rate with the physician's order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Every 72 hours is recommended for changing the administration sets of simple IV solutions

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of what? a) A systemic blood infection b) Phlebitis c) Rapid fluid administration d) An infiltration

Correct response: Phlebitis Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.

A woman age 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires what? a) An access route to replace fluids in combination with blood products b) Replacement of fluids for those lost from vomiting and diarrhea c) Intravenous fluids to be administered on an outpatient basis d) An access route to administer medications intravenously

Correct response: Replacement of fluids for those lost from vomiting and diarrhea Explanation: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

A nurse is assessing for the presence of edema in a client who is confined to bed after fracturing her femur. The nurse would pay particular attention to which area? a) Sacral area b) Hands c) Legs d) Abdomen

Correct response: Sacral area Explanation: The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. When the client is sitting or standing, the edema can be assessed in the legs. The edema cannot be assessed in the hands and abdomen, as these are not dependent areas.

The passageways of the kidney permit the urine to flow to the bladder and a) Surround the Bowman's capsule, which is where the formation of urine begins b) Selectively reabsorb or secrete substance to maintain fluids and electrolytes c) Control external sphincter of the urethra and permit the control of urination d) Act as a valve that covers the junction between the ureters and the bladder

Correct response: Selectively reabsorb or secrete substance to maintain fluids and electrolytes Explanation: The capillaries of the glomerulus are porous, and, as the blood passes through the glomerular capillaries, some constituents of the blood are filtered out

Which of the following statements accurately describes the role of antidiuretic hormone in the regulation of body fluids? When antidiuretic hormone is present, a) The frequency of voiding increases b) Urine output is increased and diluted c) The renal tubules become permeable to water d) The renal tubules become impermeable to water

Correct response: The renal tubules become permeable to water Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water.

A client who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor? a) Increased blood volume and intracellular dehydration b) Decreased blood volume and intracellular dehydration c) Decreased blood volume and extracellular overhydration d) Increased blood volume and extracellular overhydration

Decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Increased sodium levels Increased potassium levels Decreased potassium levels Decreased oxygen levels

Decreased potassium levels Explanation: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

A client is taking a diuretic such as Lasix. When implementing client teaching, what information should be included?

Decreased potassium levels - diuretics such as Lasix are potassium wasting

Pitting Edema 3+

Deep pit 6mm Remains second after pressing with skin swelling obvious by general inspection

Pitting Edema 4+

Deep pit 8mm Remains for a prolonged time after pressing with frank swelling

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?

Diarrhea Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia.

The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply.

Diarrhea Cardiac dysrhythmia

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse caring for the client knows that the client needs restoration of which of the following?

Electrolytes

A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV?

Ensure that the prescribed solution is clear and transparent

When a client age 80 years who takes diuretics for management of hypertension informs the nurse that she takes laxatives daily to promote bowel movements, the nurse assesses the client for possible symptoms of what? a) Hypothyroidism b) Hypoglycemia c) Hypokalemia d) Hypocalcemia

Explanation: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

Which of the following statements is an appropriate nursing diagnosis for an 80-year-old client with the diagnosis of congestive heart failure with symptoms of edema, orthopnea, and confusion?

Extracellular volume excess related to heart failure as evidenced by edema and orthopnea

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? a) Fluid volume deficit related to congestive heart failure, as evidenced by shortness of breath b) Fluid volume excess related to loss of sodium and potassium c) Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea d) Congestive heart failure related to edema

Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea Explanation: Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid.

Diarrhea prevention

Fecal-oral route -teach personal hygiene -Clean water supply/protect it from contamination -Careful food preparation -Handwashing

A client has been admitted to the health agency with symptoms of malnutrition. The nurse needs to administer a solution of nutrients to meet the caloric and nutritional needs of the client. The nutrient solution is packaged in a glass container and needs to be administered at a rate of 60 drops/mL. What type of tubing should the nurse use in this case?

Filtered tubing

A nurse is using an in-line filter when administering a prescribed dosage of IV fluid to a client. The nurse knows that an in-line filter is specifically used in which of the following situations?

Filtered tubing is generally used when infusing IV solutions to pediatric clients, as it removes air bubbles as well as undissolved drugs, bacteria, and large substance

Fluid volume deficit (Hypovolemia)

Fluid loss exceeds intake and electrolytes become imbalanced. Cells do not have enough water to function

Fluid Volume Excess (hypervolemia)

Fluid overload

When an elderly client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing

Fluid overload p.1452

A dialysis unit nurse caring for a patient with renal failure will expect the patient to exhibit which fluid and electrolyte imbalances?

Fluid volume excess and acidosis. Fluid volume excess can be caused by malfunction of the kidneys (i.e., renal failure

During a blood transfusion, a patient displays signs of facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?

Hemolytic transfusion reaction: incompatibility of blood product

During a blood transfusion, a patient displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?

Hemolytic transfusion reaction: incompatibility of blood product

A nurse suspects a patient with electrolyte imbalances is experiencing hypomagnesemia. What nursing assessment may indicate hypo-magnesemia?

Hyperactive deep tendon reflexes (DTRs)

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?

Hypercalcemia

Sodium excess

Hypernaturemia > 145 mEq/L

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?

Hyperphosphatemia Calcium and phosphorus have a reciprocal relationship

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase, which may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?

Hypertonic Plasma is an isotonic solution.

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which of the following intravenous solutions needs to be administered to this client?

Hypertonic solution

An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Hypokalemia

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find?

Hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. What is this electrolyte imbalance known as?

Hyponatremia p.1426

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. What is this electrolyte imbalance known as?

Hyponatremia - low concentration of sodium in the blood

Sodium deficit

Hyponaturemia < 135 mEq/L

Oral intake is controlled by the thirst center, located in which of the following cerebral areas?

Hypothalamus

The nurse is instructed by the physician that the client needs an intravenous fluid that is not likely to pull fluids into the vascular space. The nurse recognizes that the physician is suggesting which kind of fluid?

Hypotonic Explanation: A hypotonic solution has a lower osmolarity than plasma; therefore, fluid would move out of the intravascular space rather than pulling fluids from the tissues into the vascular space.

During an assessment of an elderly client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. The nurse recognizes that what medical diagnosis may be responsible?

Hypovolemia The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN).

During an assessment of an elderly client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. The nurse recognizes that what medical diagnosis may be responsible?

Hypovolemia also known as dehydration includes mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine, dry mucous membranes; warm skin

Does urine specific gravity increase or decrease with hypovolemia?

Increase

Diarrhea

Increased frequency and decreased consistency of stool

Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease?

Increased plasma levels of antidiuretic hormone lead to water excess. In addition to increased plasma levels of antidiuretic hormones, plasma levels of albumin decrease, so that the distribution of extracellular fluid changes, vascular volume decreases, and interstitial volume increases. Complications often lead to ascites

Which of the following solutions is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

Isotonic

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?

It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. p.1446

Hypervolemia nursing interventions

Location/extent of edema, daily weight (sudden increases), jugular venous distention (JVD), turn patients with dependent edema q 2 hours, VS, lungs (crackles, cough, orthopnea, dyspnea), neuro, Strict I/O, avoid constrictive clothing, sodium restrictive diet, diuretic therapy, educate pt on s/sx and when to report them

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's

Low calcium - normal total serum calcium levels range 8.9 - 10.1 mg/dL.

What organ regulates the production of CARBONIC ACID?

Lungs Carbonic acid is produced from a mixture of carbon dioxide and water

A child is eating a peanut butter sandwich. He is ingesting an excellent source of

Magnesium Good dietary sources of magnesium include green leafy vegetables, legumes, citrus fruit, peanut butter, and chocolate.

A group of nursing students are reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?

Maintenance of cell size

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? - Recording intake and output. - Testing skin turgor. - Reviewing the complete blood count. - Measuring weight daily.

Measuring weight daily. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

Metabolic alkalosis

The nurse is administering calcium carbonate, as a phosphate binder, to a client in chronic renal failure. The nurse explains that this chronic ingestion can lead to which of the following?

Metabolic alkalosis

The client's arterial blood gas results reveals a pH of 7.52, a PaO2 level of 49 mmHg and an HCO3 level of 28 mEq/L, the client is most likely experiencing what condition?

Metabolic alkalosis - excessive loss of body acids or with unusual intake of alkaline substances

A priority nursing intervention for a client with hypervolemia involves which of the following?

Monitoring respiratory status for signs and symptoms of pulmonary complications.

Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL. For what assessment findings will you be looking?

Muscle cramping and tetany, include numbness and tingling of fingers, mouth, or feet

S/sx of hypercalcemia

Nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, slurred speech, cardiac arrest

Which client has more extracellular fluid?

Newborn

Which client has more extracellular fluid?

Newborns

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium?

Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L). Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

Daily Sodium Intake Recommendation

Not more than 2,300 mg/day OR no more than 1,500 mg/day for persons 51 years of age and older.

A nurse monitoring a patient's IV infusion auscultates the patient's lung sounds and finds crackles in the bases in lungs that were previously clear. What would be the appropriate intervention in this situation?

Notify primary care provider immediately for possible fluid overload p.1476

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? -Notify the primary care provider immediately because these are signs of speed shock. -Notify the primary care provider immediately for possible fluid overload. -Check all clamps on the tubing and check tubing for any kinking. -Place the client in the Trendelenburg position to keep the client's airway open.

Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify the primary care provider immediately because the client may be exhibiting signs of fluid overload. The Trendelenburg position is not used to rectify this complication, but to help raise the blood pressure of a client with hypotension.

Dehydration nursing interventions

Oral rehydration, BRAT diet, parenteral replacement, monitor VS, MS, urine concentration, infusion rates, I & Os, breath sounds (crackles), oral hygiene

Translocation is a term used to describe the general movement of fluid and chemicals within body fluids. In every client's body, fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

Osmosis

***Respiratory

PaCO2 change with pH

The calcium level of the blood is regulated by which mechanism?

Parathyroid hormone (PTH)

Upon assessment of a patient's peripheral intravenous site, the nurse notices the area is red and warm. The patient complains of pain when the nurse gently palpates the area. What are these signs and symptoms indicative of?

Phlebitis

Upon assessment of a patient's peripheral intravenous site, the nurse notices the area is red and warm. The patient complains of pain when the nurse gently palpates the area. What are these signs and symptoms indicative of?

Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain

HPO

Phosphate

Which of the following electrolytes is a major cation in body fluid?

Potassium

A 50-year-old client with hypertension is being treated with a diuretic. The client complains of muscle weakness and falls easily. The nurse should assess which electrolyte? a) Potassium b) Chloride c) Phosphorous d) Sodium

Potassium Explanation: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia:

A 50-year-old client with hypertension is being treated with a diuretic. The client complains of muscle weakness and falls easily. The nurse should assess which electrolyte?

Potassium p.1421

Major Electrolytes in ICF

Potassium, phosphorus, magnesium

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Potassium: 5.8 mEq/L

A client is admitted to the intensive care unit with a calcium level of 4.2 mg/dL. What is the priority action by the nurse?

Prepare to administer calcium gluconate as prescribed

The renal control mechanism of restoring the acid-base balance is accomplished through which process?

Reabsorption of HCO3 and excretion of H+ restores acid-base balance through the renal control mechanisms.

A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation?

Reapply the dressing and notify the physician for further instructions.

A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation? a) Set up a sonogram for the client to determine the end point of the line. b) Reapply the dressing and notify the physician for further instructions. c) Sedate the client, remove the PICC line, and then notify the physician. d) Swab the line with sterile saline and gently reinsert the line.

Reapply the dressing and notify the physician for further instructions. Explanation: When a PICC line is not all the way out, the nurse should notify the physician. The physician will most likely order a chest x-ray to determine where the end of the PICC line is. A dressing should be reapplied before the chest x-ray, to prevent further dislodgement.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? - Remove the IV from the site and start at another location. - Immediately notify the primary care provider. - Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. - Aspirate the catheter and attempt to flush again.

Remove the IV from the site and start at another location. If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action

Remove the IV. likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid.

A decrease in arterial blood pressure will result in the release of:

Renin Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

A decrease in arterial blood pressure will result in the release of

Renin Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release

A 58-year-old woman is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires

Replacement of fluids for those lost from vomiting and diarrhea

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

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis

A patient's most recent arterial blood gases indicate a pH of 7.52 with decreased PaCO and decreased HCO-. What is this patient experiencing?

Respiratory alkalosis with compensation A pH of 7.52 constitutes alkalosis and the decreased PaCOindicates a respiratory etiology. When compensation occurs, PaCOand HCO- trend in the same direction.

Solutes

SUBSTANCES THAT ARE DISSOLVED IN A SOLUTION

Sodium Found in What Body Secretions?

Saliva Gastric and intestinal secretions Bile Pancreatic fluid

What are nursing interventions for hypovolemic shock?

Shock position, fluid replacememnt, monitor I/O, VS, LOC, safety

Pitting Edema 1+

Slight indentation 2mm Normal contours associated with interstitial fluid volume 30% above normal

Most abundant electrolyte in ECF

Sodium

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Sodium

The condition of a client with metabolic acidosis from an intestinal fistula is not improving. The pulse is 125 beats/min and the BP 84/56mm Hg. ABG values are: pH 7.1, HCO3- 18 mEq/L, PCO2 57mm Hg. What IV medication should the nurse expect to provide next?

Sodium bicarbonate

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?

Sodium is regulated by the renin-angiotensin-aldosterone system.

The nurse is educating a client about the function of sodium in the body. What education points would the nurse make? Select all that apply.

Sodium is the primary regulator of ECF volume Sodium is normally maintained in the body within a relatively narrow range, and deviations quickly result in serious health problems. Sodium participates in the generation and transmission of nerve impulses.

Electrolytes

Substances that are capable of breaking into particles called ion (holds an electrical charge)

interstitial fluid

Surrounds the tissue cells, including the lymph

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?

Tachycardia

How do we prevent fluid imbalances?

Teach & assess risk factors, observe for events, monitor fluid/food intake, mediactions

How does age affect body fluids?

The elderly have decreased thirst and dryer skin. Infants are born wet and have more ECF and more total body fluid which puts them more at risk for fluid imbalance

What are the risk factors for FVD?

The elderly, children, very ill, chronic illnesses (CHF), diet/exercise, vigorous exercise.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias

Which of the following statements accurately describes the role of antidiuretic hormone in the regulation of body fluids? When antidiuretic hormone is present,

The renal tubules become permeable to water

Which of the following statements accurately describes a guideline when using a venous access?

The system is accessed with a noncoring needle and patency is maintained by periodic flushing.

Causes of Hypovolemia

Vomiting, diarrhea, GI suctioning, inadequate fluid intake, bleeding, sweating, excess urination

Osmosis

WATER passes from greater concentration to lesser-equilibrium

Which of the following statements most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

Causes of hypervolemia

Water replacement without any electrolyte therapy, excessive water intake

S/Sx of Hypovolemia

Weight loss, sweating, decreased turgor, dry/sticking MM, weak/thready pulse, increased pulse, decreased BP, lightheadedness

Which is a common anion?

Which is a common anion? Cl- Mg+, K+, and Ca+

WO

Wide Open

Who has the least volume of body water?

Women and obese people have less body water

How does biological sex affect your body fluid?

Women have more fat distribution than men, therefore women hold less water.

S/Sx of FVE

Wt gain, peripheral edema, increased/bounding pulse (early sign), distended veins (neck/hand), dyspnea, altered LOC, I>O, JVD, Oliguria, Restless, anxiety, hypertension (early sign), extra (3rd) heart sound

A client has been admitted to the hospital after losing 20 kg (44 lb) over the past 3 months, largely due to frequent induction of vomiting. What intervention should the nurse anticipate in the treatment of the client's resulting acid-base imbalance?

a) Fluid replacement with an intravenous solution containing KCl as prescribed b) Supplementary oxygen using a non-rebreather mask c) Administration of intravenous sodium bicarbonate as prescribed d) Mechanical ventilation and administration of supplementary oxygen A

A client with ethylene glycol toxicity is restless, and stating he has flank pain. What intervention should the nurse perform to minimize complications?

a) Give aspirin for pain *b) Increase IV fluids* c) Reduce dietary calcium d) Encourage ambulation Rationale: Symptoms of ethylene glycol toxicity appear in stages. Within the first 12 hours, the client may appear drunk or comatose. In the second stage the client may develop tachycardia or pulmonary edema. During the third stage, the client may develop flank pain and renal failure as the tubules become plugged with oxalate crystals. Expanding extracellular fluid volume and hemodialysis are used to flush the toxins from the system. Aspirin is not a drug of choice because it is metabolized in the kidney.

What assessment would a nurse expect when caring for a client with metabolic alkalosis? Select all that apply.

a) Hyperactive reflexes b) Constipation *c) Dysrhythmias* d) Increased urine acidity *e) Hyperventilation* Rationale: Conditions that cause acidosis suppress neural excitability, so as the condition progresses, clients become lethargic, stuporous, or comatose. By comparison, alkalosis causes irritability, hyperactive reflexes, and sometimes convulsions. Life-threatening dysrhythmias may occur. The kidneys attempt to conserve hydrogen ions, decreasing the urine acidity. When the lungs compensate, the client will have slow, shallow breathing.

A client has these arterial blood gas values: anion gap 20 mEq/L, pH 7.29, pCO2 37mm Hg, HCO3- 11 mEq/L, base excess -6 mEq/L. With what condition do these values correspond?

a) Hyperkalemia b) Lactic acidosis c) Multiple myeloma d) lithium toxicity B

The nurse is caring for a client with worsening respiratory acidosis. Which of these interventions does the nurse anticipate if the client's condition continues to deteriorate?

a) Mechanical ventilation b) Introduction of large muscle exercise c) Resolution of the underlying emotional cause d) Reducing the amount of supplemental oxygen A

what do you look at for vein selection?

accessibility and condition of a vein, age and size of the patient, type of fluid to be infused, anticipated duration of infusion, patient diagnosis

Arterial blood gas values indicate what?

acid-base status

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

acidic

who can encounter fluid imbalances

acutely and chronically ill patients

what is energy in the form of for active transport

adenosine triphosphate (ATP)

A client with dehydration will have an increase in:

aldosterone

Major control over the extracellular concentration of potassium within the human body is exerted by:

aldosterone.

A nurse flushing a capped peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation?

aspirate and attempt to flush the line again

what is the healthy adult fluid intake

average intake: 2,600 mL per day ingested water: 1,300 mL ingested food: 1,000 ml metabolic oxidation: 300 mL

what is the healthy adult average fluid loss?

average loss: 2,600 mL per day urine from kidneys: 1,500 ML evaporation from skin: 600 mL evaporation from lungs: 300 mL stool from GI tract: 200 mL

Why do women and obese people have less body water?

b/c of adipose taking up a lot of the space

what are some examples of laboratory studies for fluid imbalances

basic metabolic panel (BMP), comprehensive metabolic panel (CMP), urine pH (urinalysis), arterial blood gas, BUN/ creatine

what are some indications for an isotonic solution

blood loss (surgery), dehydration, vomiting and diarrhea, fluid restrictions

intravascular fluid

blood plasma

the lungs are the main controller of what

body's carbonic acid supply

Bicarbonate function in body

body's primary buffer system

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

calcium and phosphorus

Uses of TPN

cancer, bowel disorders, trauma, extensive burns

what is insensible losses

cannot be measure such a fluid evaporation through the skin and water vapor form the lungs during respiration (increase loss with rapid RR) (hyperventilation= more at risk for dehydration)

Magnesium function in body

carbohydrate and protein metab, enzyme activity (important for brain activity)

***Respiratory alkalosis

carbonic acid deficit

***Respiratory acidosis

carbonic acid excess

Potassium is needed for neural, muscle, and:

cardiac function.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

what should be included in the history and physical assessment

changes in vital signs, skin turgor, oral mucucosa, appearance of skin, edema history of excessive thirst, N/V, or diarrhea

Phosphate function in body

chemical reactions in body, cell division, and hereditary traits

what does potassium do in the body and value

chief regulator of cellular enzyme activity and water content value- 3.5-5.0 mEq/L

Which client would be a candidate for total parenteral nutrition?

client with colitis & bloody diarrhea, TTN is needed when there is an interference with nutrient absorption from the GI, or when complete bowel rest is necessary for healing

what is tonicity

comparing osmolarity of 2 solutions usually blood

if you have an increase in solutes what is it?

concentrated

what is alkalosis

condition in which exceeds 7.45. characterized by: lack of hydrogen ions in the extracellular fluid.

what is acidosis

condition in which pH falls below 7.35. characterized by excess of hydrogen ions in the extracellular fluid

What does the CNS help maintain in homeostasis?

control fluid balance (ADH). (epic and norepinephrine is controlled under this)

What do the Adrenals help maintain in homeostasis?

control sodium, chloride and water, and excrete potassium.

what does sodium do in the body and value

controls and regulates volume of body fluids value- 135-145 mEq/L

A client has been admitted with fluid volume excess related to left sided heart failure. Which assessment data would the nurse document related to the fluid volume excess? (Select all that apply.)

crackles in the lungs distended neck veins and DECREASED URINE OUTPUT

A patient has been admitted to the hospital with a diagnosis of acute renal failure, a health problem that necessitates monitoring of the patient's fluid. What is the most accurate way that the care team can achieve this assessment goal?

daily weights are considered one of the more accurate measures of fluid balance.

By reabsorbing HCO3- from the glomerular filtrate and excreting H+ from the fixed acids that result from lipid and protein metabolism, the kidneys work to return or maintain the pH of the blood to normal or near-normal values. How long can this mechanism function when there is a change in the pH of body fluids?

days Explanation: The renal mechanisms for regulating acid-base balance cannot adjust the pH within minutes, as respiratory mechanisms can, but they continue to function for days, until the pH has returned to normal or near-normal range. It is the respiratory system that responds within minutes to return the body's pH near to its normal limits.

what does third-spacing result in

decreased albumin, heart failure, renal dysfunction, hyponatremia

Dehydration

decreased volume of water and electrolytes

what is hypovolemia

deficiency in amount of water and electrolytes in ECF with near-normal water/electrolyte proportions. fluid becomes hypertonic and cellular fluid is drawn into the interstitial space, leaving cells without sufficient fluid to function

Hypovolemia

deficiency of water and electrolytes in ECF with near normal water/electrolyte proportions

what are some implementation for fluid imbalances

dietary modification, modification of fluid intake, medication administration, IV therapy, blood and blood products, TPN, relieving patient anxiety as needed

if you have a decrease in solutes than you have what?

dilution

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended.

what are diuretics?

drugs that increase renal excretion of water, sodium and other electrolytes, increase risk of fluid volume deficit, careful monitoring of fluid intake/output and serum electrolytes, teach patient about diuretics therapy, precautions, and side effects.

What are the symptoms of FVE?

edema, adventitious lung sounds (crackles)

Fluid Imbalances involve what?

either volume or distribution of water - OR - electrolytes

The passageways of the kidney permit the urine to flow to the bladder and

electively reabsorb or secrete substance to maintain fluids and electrolytes

A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her:

electrocardiogram (ECG) results.

Complications of diarrhea

electrolyte imbalances, dehydration, malabsorption

Hypervolemia

excess water and sodium in ECF

Edema

excessive ECF accumulates in tissue spaces or interstitial spaces

what is edema

excessive ECF accumulates in tissue spaces. accumulates of fluid the lungs and dependent part of the body

what is hypervolemia

excessive retention of water and sodium in ECF. increased osmotic pressure causes fluid to be pulled from the cells

Severe s/sx of dehydration

excessive thirst, lack of sweat production, low b/o, rapid heart rate, rapid breathing, fever, sunken eyes, dark urine, heat exhausted/cramps, seizures, low blood volume, kidney failure, coma, shock

what does the kidneys do for pH?

excrete or retain hydrogen ions and form or excrete bicarbonate ions in response to pH of the blood

When an 80-year-old client who takes diuretics for hypertension informs the nurse she take laxatives daily for bowel movements, the nurse assesses the client for possible symptoms of

excretion of potassium and magnesium from the body, increases the risk for fluid and electrolyte deficits

Respiratory mechanism

expire CO2

what is a pH?

expression of hydrogen ion concentration and resulting acidity of a substance (measurement of the acid-base balance)

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

where can edema be observed

eye, fingers ankles, feet, legs, and sacrum

Extracellular fluid (ECF)

fluid outside the cells; includes intravascular and interstitial fluids

what happens when using a hypotonic solution

fluid shifts form hypotonic solution into the more concentrated solution of the cell to create a balance (the cell swell- can burst) (very dehydrated)

what is the fluid shift in a hypertonic solution

fluid shifts into the blood vessel, out of the cell, and out of the tissue

Mr. Smith is admitted to your unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is

fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body.

Intracellular fluid (ICF)

fluid within cells

Intracellular fluid (ICF)

fluid within cells (70%)

what is osmotic pressure

force required to push a solvent through a solution. more solutes= more concentration= higher osmotic pressure less solutes= less concentration= lower osmotic pressure

What foods can the nurse recommend for the patient with hypokalemia?

fruits such as bananas and apricots

what is a hypertonic solution

greater concentration of particles than plasma (>295)

Risk factors of hypervolemia

heart failure, cirrhosis, increased glucocorticosteriods, kidney failure, fluid shifts, burns, excessive sodium intake

what does the adrenal gland do?

helps the body conserve sodium, save chloride and water, and excrete potassium

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia.

what are some indications for a hypertonic solution

hyponatremia, cerebral edema, other edema.

dehydration vs hypovolemia

hypovolemia results from loss of electrolytes and water dehydration results from loss of water alone

what should be included in the nursing assessment

identify patients at risk for fluid volume imbalances (old adults, babies, kidney problems, CHF) determine that a specific imbalance is present and its severity, etiology, and characteristics,

Who has more body fluid and ECF infants or adults?

infants so they are more prone to fluid volume deficits

causes of diarrhea

infection, ingestion of toxins, food allergens, drug reactions, inflammatory disease, malabsorption problems

what are some sources of water intake

ingested liquids, food, and byproducts of metabolism (oxidation)

what does the nervous system do?

inhibits and stimulates mechanisms influencing fluid balance

A nurse is preparing to start an intravenous infusion for a patient after a mastectomy. Which of the following accurately describes an assessment that should be made before starting the infusion?

initiate venipuncture at least 2 inches above the crease of the wrist in an adult

A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV?

inspect the container and determine that the solution is clear and transparent, expiration date, no leaks, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

what does phosphate do in the body and value

involved in important chemical reaction in the body, cell division, and hereditary traits value- 2.5-4.5 mg/dL

s/sx of hypophosphatemia

irritability, fatigue, nausea, muscle weakness, tachycardia

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

isotonic

What is used for extracellular volume replacement?

isotonic solution

what can be a transfusion reaction

itching, fever, chills, dyspnea, lower back pain, abdominal pain, flushed skin.

What is the primary organ for homeostasis?

kidney

what is a hypotonic solution

lesser concentration of particles than plasma (<275)

solvents

liquids that hold a substance in solution

what is a solvent

liquids that hold a substance in solution (water)

A child is eating a peanut butter sandwich. He is ingesting an excellent source of

magnesium - green leafy vegetables, legumes, citrus fruit, peanut butter, and chocolate

what are some expected outcomes for fluid

maintain approximate fluid intake and output balances, maintain urine specific gravity within normal range, practice self-care behaviors to promote balance in fluid, electrolyte, and acid-base; maintain adequate intake of fluid and electrolytes, respond appropriately to body's signals of impending imbalances

who has the most and least amount of water in the body

most amount- infants; they have the most fat and more prone to fluid volume volume deficits (70-80% of water) least amount- older adults they do not have as much adipose tissue (45-55% of water)

what are intravenous therapy

most common treatment for managing fluid volume or electrolyte imbalances, type and amount of IV fluids depends on patient condition, nurse responsible for initiating, monitoring and discontinuing imbalances

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?

muscle cramping and tetany (muscle spasms) hypercalcemia = nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. hyperchloremia = diminished cognitive ability and hypertension Constipation is a sign of hypercalcemia.

s/sx of hypomagnesemia

muscle weakness, tremors, tetany, seizures, heart block, change in mental status, hyperactive DTR, respiratory paralysis

why is the acid-base balance important?

must be maintained to sustain health, homeostasis, and life.

what does hypermagnesemia result in

nausea, vomiting, weakness, flushing, leathery, respiratory depression, coma, and cardiac arrest

s/sx of hypermagnesemia

nausea, vomiting, weakness, loss of DTR, respiratory depression, coma, cardiac arrest

what does calcium do in the body and value

nerve impulses, blood clotting, muscle contraction, b12 absorption value- 8.6-10.2 mg/dL

S/Sx of hypernatremia

neurologic impairment, restlessness, weakness, disorientation, delusion, hallucinations, brain damage

nonelectrolytes

no charge

A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid?

no intravenous solution

Potassium is needed for neural, muscle, and

normal cardiac & muscle function

what are some examples of an isotonic solution

normal saline (used for blood products), Lactated Ringers, 5% dextrose in water, colloids (blood products)

Which of the following is a correct route of administration for potassium?

oral

A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply.

orthostatic hypotension decreased urine output slow-filling peripheral veins The signs and symptoms of decreased interstitial volume include dry mucous membranes and poor skin turgor.

Chloride function in body

osmotic pressure in blood, produces hydrochloric acid

what are the steps of the fluid shift for a hypotonic solution

out of the blood plasma, into the cell

what is an example of diffusion

oxygen and carbon dioxide exchange in the lungs

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

pH 7.48

A patient informs the nurse of a problem with acid indigestion and has been taking large amounts of calcium carbonate antacids daily but still has no relief. The patient states that he can consume a bottle of 100 antacids in 4 days. Which of the following blood gas results does the nurse anticipate assessing?

pH 7.6

***Alkalosis

pH above 7.45

The nurse caring for a client with metabolic acidosis examines arterial blood gas (ABG) results. Which change from the initial value indicates the client's metabolic acidosis is improving?

pH has increased

Filtration

passage of fluid through permeable membrane from area of higher pressure to lower pressure (needs pressure to move fluids)

where can intravenous therapy be located

peripheral venous catheters, midline peripheral catheter, central venous access device, implanted ports

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

potassium

deviation intake/output= ?

potential imbalance

what is respiratory alkalosis

primary deficit of carbonic acid in ECF

what is metabolic alkalosis

primary excess of bicarbonate in ECF

what is respiratory acidosis

primary excess of carbonic acid in ECF.

what is metabolic acidosis

proportionate deficit of bicarbonate in ECF

how would you measure a patients fluid intake?

provide an explanation of the rationale along with instructions for how the patient can help keep measurements accurate, instruct the patients and family regarding the need for record, use patient's plan of care to communicate to other nursing personnel the need to measure fluid, record intake and output totals for each 8 hour shift and total each 24 hours.

What does the parathyroid gland help maintain in homeostasis?

regulate the level of calcium in ECF.

Sodium function in body

regulates volume of body fluids, AP

Potassium function in body

regulator intracellular enzyme activity, AP

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? excessive use of laxatives diaphoresis renal failure increased cardiac output

renal failure Explanation: Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

A decrease in arterial blood pressure will result in the release of:

renin.

what is active transport

requires energy for movement of substances through the cell membrane from the lesser solute concentration to the higher solute concentration (pumping uphill)

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis.

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.

respiratory muscle weakness confusion ventricular dysrhythmia

what can cause third spacing

severe burns, bowel obstruction, surgical procedures, pancreatitis or sepsis

What is third spacing?

shift of body fluids into the transcellular department, can cause an ECF volume deficit

S/Sx of hypokalemia

skeletal muscles show first signs, muscle weakness, leg cramps, heart dysrhythmias

Which one of the following electrolyte imbalances occurs due to a sodium deficit in ECF caused by a loss of sodium or gain of water?

sodium deficit in ECF caused by a loss of sodium or gain of water

The primary extracellular electrolytes:

sodium, chloride, and bicarbonate

Diffusion

solutes move to equal distribution throughout a solvent (PARTICLES move from an area from high concentration to less)

what does the pituitary gland do?

stores and releases ADH

Acid

substance containing hydrogen ions that can be liberated or released

what is a solute

substance dissolved in a solution (electrolyte and nonelectrolyte) (electrolytes, sugar, salt) (particles)

what is an electrolyte

substance that are capable of breaking into particles called ions and developing an electric charge when dissolved in a solution

Base

substance that can trap hydrogen ions

what are bases?

substance that can trap hydrogen ions, they accept hydrogen ions, from acids to neutralize or decrease the strength of a base or to form a weaker acid

what is an acid

substance that contains hydrogen ions and are hydrogen ion donors, which means that acid gives up hydrogen ions to neutralize or decrease the strength of an acid or to form a weaker base

solutes

substances that are dissolved in a solution

how does the lungs help out with the buffer system

surface area of lungs and ability to diffuse carbon dioxide can cause rapid changes to pH when needed by the body

Mr Powell, a dehydrated 35 year old has intravenous fluid running at 250 cc/h. for rapid rehydration. He is complaining of burning at the site. You see no redness, swelling, heat, or coolness upon inspection. You suspect

that the fluid is infusing too rapidly

the kidneys are the primary controller of what

the body's bicarbonate supply

how does potassium help during the acid base balance during alkalosis

the cells release hydrogen ions into the blood in an attempt to increase the acidity of the blood; this forces the potassium into the cells and potassium level decrease.

what is osmolarity

the concentration of particles in a solution or "pulling power" more solute- higher osmolarity, more concentrated less solute- lower osmolarity, more dilutes

what does the kidneys do when alkalosis is present

the kidney's retain hydrogen and excrete bicarbonate- decreased pH

what does the kidneys do when acidosis is present

the kidneys excrete hydrogen and form/conserve bicarbonate- increased pH

Which of the following statements accurately describes the role of antidiuretic hormone in the regulation of body fluids? When antidiuretic hormone is present,

the renal tubules become permeable to water

Which of the following statements accurately describes a guideline when using a venous access?

the system is accessed with a noncoring needle and patency is maintained by periodic flushing

Who's at risk for dehydration?

the very old, the very young, acute illness, chronic illness, vigorous exercise, diet and lifestyle

what is the result of osmosis

the volume of more concentrated solution increases, the volume of weaker solution is decreased, and homeostasis is equalized on both sides of cell membrane.

what does the hypothalamus do

thirst control center of the body

s/sx of dehydration

thirst, dark urine, dry mouth, exhaustion, few/no tears, muscle weakness, dizziness, headache

When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. What is the most likely complication that has occurred?

thrombus

When administering an IV solution, the solution is placed at least 18 to 24 inches above the site of the infusion. Why?

to overcome the pressure in vein

A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. Which of the following reasons explains the nurse's action?

to prevent compromising circulation

homeostasis

total cations equal to total anions

what is homeostasis

total cations= total anions

the patients output include the following

urine, vomitus, diarrhea, drainage from fistulas, wounds, ulcers; and drainage from suctioning devices or other tubes, stuff in diapers or bed clothes need to be estimated, hyperventilation also noted on the output record. Record the rate and depth of respirations.

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which of the following actions should the nurse perform?

weighs wet linens, pads, or dressings and subtracts the weight of a similar dry item

A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation?

when a PICC line is not all the way out, the nurse should notify the physician. The physician will most likely order a chest x-ray to determine where the end of the PICC line is. A dressing should be reapplied to prevent further dislodgement.

what does the lungs do during acidosis

when carbon dioxide in the blood decreases, medulla is stimulated to decrease respiratory rate and depth= increased retention of carbon dioxide and decreased pH of the blood

what does the lungs do during alkalosis

when the CO2 in the blood increases, the medulla is stimulated to increase respiratory rate and depth= increase elimination of carbon dioxide and increased pH of the blood

when does fluid imbalances occur?

when the body's compensatory mechanisms are unable to maintain a homeostatic state.

Which client will have more adipose tissue and less fluid?

women have lower fluid because they have more adipose then men.

A nurse is choosing a vein to start an IV infusion in a patient. Which of the following are recommended veins to use when initiating an IV infusion?

• Cephalic vein • Metacarpal • Basilic veins • Superficial veins on the dorsal aspect of the hand

You are the nurse caring for Jason Kent, a 16-year-old who got lost while on a desert hike. He was found after spending two days without food or water and was admitted to your unit through the Emergency Department. He is severely dehydrated and sunburned. You remember that which of the following are reasons why the human body requires fluid? Choose all that apply.

• Facilitates cellular metabolism • Helps maintain normal body temperature • Acts as a solvent for electrolytes

A nurse is caring for a client with dehydration. Which of the following signs are observed in a client with dehydration? Select all that apply

• Skin turgor over sternum • Decreased blood pressure • Low urine output

An obese client with lung cancer needs intermittent infusion of IV solution and medication for several months. Which of the following central venous catheters is most suitable for long-term access in a cancer client without the catheter protruding from the skin?

• Tunneled • Peripherally • Implanted

A nurse is caring for an obese client with lung cancer who needs intermittent infusion of IV solution and medication for several months. Which of the following central venous catheters is most suitable for long-term access in a cancer client without the catheter protruding from the skin? Select all that apply.

• Tunneled catheters • Peripherally inserted central catheter • Implanted access device

The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.)

• drinking milk • urination • vomiting • infusion of intravenous solution Explanation: The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output.

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? - "Infiltration is the inflammation of the vein, while phlebitis is a localized irritation." - "Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." -"Infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed." -"Infiltration occurs when an IV is improperly placed, and phlebitis indicates circulatory overload."

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

Which of the following is considered an isotonic solution?

0.9% normal saline

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?

In metabolic acidosis, arterial blood gas results are anticipated to reflect pH guch as 64; 42.

Transcellular Fluid

Includes cerbrospinal fluid, pericardial fluid, synovial fluid, intraocular fluid and pleural fluids, as well as sweat and digestive secretions

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

Increases arterial pH

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's

Low calcium p.1421

What is the nurse's expectation about a client's ability to compensate for a metabolic blood gas disorder?

The client will compensate with the respiratory system.

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action? Discontinue the IV. Attempt to aspirate. Flush with 3-mL normal saline. Slow the rate of infusion by 50%.

discontinue the IV infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor. Aspiration is never performed from a peripheral IV. Flushing or slowing the infusion will not alleviate this problem.

what is interstitial fluid

fluid surrounding tissue cells

What is intracellular fluid?

fluid that exist inside the cells (70% of total fluid) most common cation in intracellular fluid is potassium

Hypokalemia patient lab result show a serum potassium of 3.2 mEq/L. For what should you be alert?

muscle weakness, fatigue, & dysrhythmias (3.5 - 5)

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?

ongoing verification of the IV solution and the infusion rate with the physician's order.

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.

what are some functions of water in the body

transporting nutrients to cells and wastes from cells, transporting hormones, enzymes, blood platelets, acts as a solvent for electrolytes and non electrolytes

The body regulates the pH of its fluids by what mechanism? (Select all that apply.)

*• Chemical buffer systems of the body fluids* *• The lungs * *• The kidneys* Rationale: The pH of body fluids is regulated by three major mechanisms: (1) chemical buffer systems of the body fluids, which immediately combine with excess acids or bases to prevent large changes in pH; (2) the lungs, which control the elimination of CO2; and (3) the kidneys, which eliminate H+ and both reabsorb and generate HCO3-.

What does water in the body facilitate?

-Facilitates cellular metabolism -Facilitates digestion and promotes elimination

What are the two Major Compartments of Fluid in the Body?

-Intracellular fluid (ICF) -Extracellular fluid (ECF)

What does water in the body transport?

-Transporting nutrients and wastes -Transporting hormones, enzymes, platelets, wbc/rbc

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? 1- Prepare to assist with ventilation. 2- Monitor the client's heart rhythm. 3- Prepare for gastric lavage. 4- Obtain a urine specimen for drug screening.

1

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas p.1435

A patient's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. What signs and symptoms should the nurse vigilantly monitor for?

Cardiac irregularities p. 1427

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation? a) Check all clamps on the tubing and check tubing for any kinking. b) Notify the primary care provider immediately because these are signs of speed shock. c) Notify the primary care provider immediately for possible fluid overload. d) No intervention is necessary as this is a normal finding with IV infusion.

Correct response: Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated, notify the primary care provider immediately. The client may be exhibiting signs of fluid overload. Be prepared to tell the health care provider what the past intake and output totals were, as well as the vital signs and pulse oximetry findings of the client.

Mr Powell, a dehydrated 35 year old has intravenous fluid running at 250 cc/h. for rapid rehydration. He is complaining of burning at the site. You see no redness, swelling, heat, or coolness upon inspection. You suspect a) Infiltration b) That the fluid is infusing too rapidly for comfort c) That something is wrong with the IV fluid d) Phlebitis

Explanation: The fluid is infusing too rapidly. You should slow the infusion to 200 cc/h.

The primary extracellular electrolytes are: a) Sodium, chloride, and bicarbonate b) Phosphorous, calcium, and phosphate c) Magnesium, sulfate, and carbon d) Potassium, phosphate, and sulfate

Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.

What does water in the body help maintain?

Helps maintain normal body temperature

When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which guideline should the nurse follow?

Use distal veins before proximal veins leaving the more proximal sites for later venipunctures.

what is extracellular fluid

fluid that exist outside the cells. most common cation outside the cells is sodium (30% of total fluid)

what is intravascular fluid

outside the cell, but also inside the blood vessels (plasma of the blood)

The nurse is caring for a client with metabolic alkalosis. Which of these arterial blood gas results supports this diagnosis?

pH of 7.50 and HCO3 of 45 mEq/L

A client with renal disease requires IV fluids. It is important for the nurse to

place the fluid on an electronic devise

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action? Assess oxygen levels. Stop the transfusion. Assess for visible rash. Call for assistance.

stop the transfusion Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.

A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and his family? Select all that apply.

• Respond to thirst • Drink water as an inexpensive way to meet fluid needs. • Drink at least eight glasses of fluid each day

Variations in Fluid Content

- Can occur based on factors such as age, body fat and gender. - it differs by fat cells because fat cells contain little water, wheras lean tissue is rich in water. Thus, the more obese a person is, the smaller the person's percentage of total body water is when compared with body weight. Because women tend to have proportionally more body fat than men do, they also have less body fluid than men. - The decreasing percentage of body fluid in older people is related to an increase in fat cells. - Older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water. - After age 60, total body water is about 45% of a person's body weight.

Fluid Balance

- Regulated primarily by the thirst mechanism located within the HYPOTHALAMUS - The thirst center is stimulated by intracellular DEHYDRATION + decreased BLOOD VOLUME - Water contained in food is the second largest source of water for the body + the amount of water ingesteddepends on the diet - Water is an END PRODUCT of the oxidation that occurst during the metabolism of food substances, specifically carbohydrates, fats and protein

Intercellular Fluid (ICF)

- The fluid WITHIN cells - 70% of the total body water - 50% of the adult's body weight - Includes lymph

What does water in the body act as?

-Acts as a solvent for electrolytes and solutes -Acts as a lubricant

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? 1- "I can use laxatives and enemas but only once a week." 2- "A good breakfast for me will include milk and a couple of bananas." 3- "I will be sure to buy frozen vegetables when I grocery shop." 4- "I will take a potassium supplement daily as prescribed."

1

Which of the following arterial blood gas results would be consistent with metabolic alkalosis? 1- Serum bicarbonate of 28 mEq/L 2- PaCO2 less than 35 mm Hg 3- Serum bicarbonate of 21 mEq/L 4- pH 7.26

1

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? 1- Lung function 2- Summer allergies 3- Cardiovascular compromise 4- Insensible fluid loss

4

The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)? 1- Osmosis 2- Passive diffusion 3- Facilitated diffusion 4- Active transport

4

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? An implanted central venous access device (CVAD) A peripheral venous catheter inserted to the antecubital fossa A peripheral venous catheter inserted to the cephalic vein A midline peripheral catheter

An implanted central venous access device (CVAD) Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV? • Insert the largest gauge possible to maximize flow and minimize the risk of occlusion. • Clean the insertion site daily using sterile technique. • Flush the catheter every six hours with hypertonic solution if the IV is not in constant use. • Change the site every three to four days.

Correct response: • Change the site every three to four days. Explanation: Peripheral IV sites should be rotated every 72 to 96 hours, depending on the institutional protocol. IV insertion sites are not cleansed daily, but the site should be assessed per institutional protocol or every nursing shift. Flushes are not necessary every six hours. Hypertonic solution is not used for IV flushes. The smallest gauge that is practical should be inserted in order to minimize trauma.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L) a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? • muscle weakness • cardiac irregularities • increased intracranial pressure (ICP) • metabolic acidosis

Correct response: • cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosophorus. Increased intracraniel pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

• A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: • electrolytes. • nonelectrolytes. • interstitial fluid. • colloid solution.

Correct response: • electrolytes. Explanation: The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of: • hyponatremia. • fluid volume excess. • hypovolemia. • metabolic acidosis.

Correct response: • fluid volume excess. Explanation: Edema is a characteristic sign of fluid volume excess (hypervolemia). Metabolic acidosis is a decrease of the client's pH and increase in the carbon dioxide. Hyponatremia is a low sodium level and not associated with peripheral edema. Hypovolemia is a decrease in blood pressure. Peripheral edema is not consistent with hypovolemia but hypervolemia.

A client age 80 years who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: • hypokalemia. • hypothyroidism. • hypoglycemia. • hypocalcemia.

Correct response: • hypokalemia. Explanation: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: • hypernatremia. • hypokalemia. • hyponatremia. • hyperkalemia.

Correct response: • hyponatremia. Explanation: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which of the following interventions should the nurse perform for this complication? a) Elevate the client's head. b) Apply a warm compress. c) Apply antiseptic and a dressing. d) Position the client on the left side.

Correct response: Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? a) Fluid volume deficit related to congestive heart failure, as evidenced by shortness of breath b) Congestive heart failure related to edema c) Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea d) Fluid volume excess related to loss of sodium and potassium

Correct response: Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea. Explanation: Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is which of the following? a) Fluid volume deficit b) Myocardial Infarction c) Fluid volume excess d) Atelectasis

Correct response: Fluid volume excess Explanation: A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess.

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?

Correct response: It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. Explanation: The nurse's ongoing verification of the IV solution and the infusion rate with the physician's order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Every 72 hours is recommended for changing the administration sets of simple IV solutions.

What is an appropriate nursing diagnosis for an 80 yr old with the diagnosis of congestive heart failure with symptoms of edema, orthopnea & confusion?

Extracellular volume excess related to heart failure as evidence by edema and & orthopnea

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? -Remove the IV catheter and reinsert another in a different location. -Decontaminate the visible portion of the catheter, and then gently reinsert. - Apply a new dressing and observe for signs of infection over the next several hours. -Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.

Remove the IV catheter and reinsert another in a different location. Explanation: An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site

why is fluid and water important?

adequate balance in imperative to maintain healthy functioning of the body and fluid and electrolytes are vital to life

A client with a long history of alcohol abuse has been admitted to the emergency department after several of days of heavy drinking. The nurse can best promote the restoration of the client's acid-base balance by:

administering intravenous sodium bicarbonate as prescribed.

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes. Non-electrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.