Prep U Fluid and Electrolytes

What is the primary goal of nursing care during the emergent phase after a burn injury?

Replacing lost fluids Rationale: During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia to prevent circulatory collapse

As status asthmaticus worsens, the nurse would expect the client to experience which acid-base imbalance?

Respiratory acidosis Rationale: As status asthmaticus worsens, the PaCO increases and the pH decreases, reflecting respiratory acidosis.

What acid base imbalance is likely to occur in a patient who has COPD due to their decreased CO2 elimination abilities?

Respiratory acidosis Rationale: Increased carbon dioxide tension in arterial blood leads to respiratory acidosis and chronic respiratory failure.

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?

The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing Rationale: Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide level, they may stop breathing.

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?

Urine output of 30ml/hr Rationale: Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation.

What acid base imbalance is associated with overuse of sodium bicarbonate tablets?

Metabolic alkalosis Rationale: Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations.

What acid base imbalance is likely to occur in a patient with excessive vomiting?

Metabolic alkalosis Rationale: Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.

A client has been taking furosemide for 2 days. The nurse should review the laboratory record for changes in which blood level?

Decreased potassium Rationale: furosemide is a loop diuretic reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle resulting in loss of potassium

The client comes to the clinic and is prescribed a diuretic. The client asks the nurse, "What does a diuretic do?" What is the best response by the nurse? Select all that apply.

"A diuretic will inhibit the reabsorption of sodium." "A diuretic will increase the loss of water." Rationale: Diuretics prevent sodium reabsorption and the water that follows sodium will also be excreted

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization?

Assess puncture site for swelling and bleeding Rationale: Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization

The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. How much fluid should the nurse tell the client to drink?

At least 3,000ml of fluid per day Rationale: Nurse should over generalized instructions and be specific

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's

Blood pressure Rationale: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure.

When administering IV replacement of 5% dextrose in water with potassium chloride, what should the nurse do first?

Check electrolyte lab values Rationale: IV solutions are prescribed based upon the fluid and electrolyte status of the client, so laboratory results should be monitored first

Which physical sensation will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises?

Dizziness Rationale: Hyperventilation occurs when the client breathes so rapidly and deeply that she exhales excessive amounts of carbon dioxide. A characteristic symptom of hyperventilation is dizziness.

A nurse is caring for a client with chronic renal failure. The nurse receives the arterial blood gas result pH-7.19, PCO2- 42mmHg (5.59 kPa), Po2- 88mm Hg (11.70 kPa), HCO3-15mEq/L (15.00 mmol/L). What are the priority action(s) by the nurse? Select all that apply.

Encourage rest. Record intake and output. Prepare for possible seizures. Administer sodium bicarbonate. Rationale: The priority action by the nurse is seizure precautions, administering sodium bicarbonate to act as a bronchodilator, encouraging rest, and recording intake and output. Appling noninvasive positive-pressure ventilation is used for respiratory acidosis.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

Fluid volume excess Rationale: A client with renal failure can't eliminate sufficient fluid. This issue increases the risk of fluid overload and consequent respiratory and electrolyte problems.

Which action will the nurse implement first to help improve respiratory alkalosis in a patient who is having respirations at 46 per minute?

Have patient breathe into a paper bag Rationale: client who experiences respiratory alkalosis should breathe into a paper bag to increase arterial carbon dioxide tension and ease anxiety (which may exacerbate the alkalosis)

A primary health care provider prescribes regular insulin 10 units intravenously (I.V.) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

Hyperkalemia Rationale: Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia.

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

Hyperkalemia Rationale: Hyperkalemia is a complication of acute renal failure

A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect?

Hyperkalemia Rationale: Spironolactone is a potassium-sparing diuretic; therefore, clients should be monitored closely for hyperkalemia.

Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?

Hypertonic Rationale: A hypertonic solution causes the bloodstream to absorb fluids until pressure on both sides of the blood vessel is equal. A hypotonic solution causes fluids to move from the bloodstream into the tissues. An isotonic solution has no effect on the cell.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?

Lactated ringer's Rationale: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn.

What is the first indication of a serious complication in a patient receiving IV therapy?

Noisy respirations Rationale: A serious complication of IV therapy is fluid overload. Noisy respirations can develop as a result of pulmonary congestion.

After a total laryngectomy, the client has a feeding tube. What is the purpose of the feeding tube?

Provide nutrition Rationale: The goal of postoperative care is to maintain physiologic integrity. Therefore, inserting a feeding tube is a strategy to ensure the fluid and nutritional needs of the client as the surgical site is healing.

What is the kidney's function in maintaining the acid base balance?

Returning bicarbonate to the body's circulation

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

Sodium level of 124 Rationale: In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L.

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?

Development of hypocalcemia Rationale: Hypocalcemia develops in severe cases of acute pancreatitis. The exact cause is unknown. Signs and symptoms of hypocalcemia include jerking and muscle twitching, numbness of fingers and lips, and irritability.

The nurse is caring for a client with polydipsia and large amounts of urine with a specific gravity of 1.003. Which disorder is anticipated?

Diabetes insipidus Rationale: Diabetes insipidus is characterized by a great thirst (polydipsia) and large amounts of dilute, watery urine with a specific gravity of 1.001 to 1.005.

Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet?

Canned tomato juice Rationale: Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet.

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

Chronic respiratory acidosis Rationale: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis

Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?

Hypertonic Rationale: The osmolarity of a hypertonic solution is higher than that of serum. A hypertonic solution draws fluid into the intravascular compartment from the intracellular and interstitial compartments

A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours, the tube has drained 2 L of fluid. The nurse should further assess the client for which electrolyte imbalance?

Hypokalemia Rationale: Loss of electrolytes from the gastrointestinal tract through vomiting, diarrhea, or nasogastric suction is a common cause of potassium loss, resulting in hypokalemia.

What is an early sign of acute respiratory stress syndrome?

Hypoxia not responsive to O2 therapy Rationale: A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen.

A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action?

Prepare for C-section Rationale: Fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium-stained amniotic fluid and bradycardia are further signs of fetal distress that warrant cesarean birth.

What is magnesium sulfate used for in a pregnant woman who has preeclampsia?

Prevent seizures Rationale: The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system caused by preeclampsia by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.

A client is prescribed digoxin as treatment for heart failure. Which should the nurse monitor while the client is receiving this medication?

Serum potassium and magnesium Rationale: During digoxin therapy, the serum potassium and magnesium levels should be closely monitored because hypokalemia or hypomagnesemia can lead to the development of digoxin toxicity.

A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which result is consistent with this disorder?

pH 7.28, PaO2 50 mm Hg Rationale: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

Which pair of organs is responsible for regulatory processes and compensation?

Lungs and kidneys Rationale: The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take?

IV admin of lactated ringers

An older adult client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and hyperthermia. Which admission order would the nurse implement first?

IV fluid hydration Rationale: history and assessment both indicate dehydration and should be treated as a first priority

The nurse is caring for a client following a motor vehicle incident with head trauma. Diabetes insipidus is suspected. Which nursing intervention is appropriate?

Measure and record urine output Rationale: Diabetes insipidus is characterized by polydipsia - as much as 8L/day, constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output.

The nurse determines that interventions for decreasing fluid retention have been effective when the nurse makes which assessment in a child with nephrotic syndrome?

Decreased abdominal girth Rationale: Fluid accumulates in the abdomen and interstitial spaces due to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues.

The nurse is teaching an older adult with a urinary tract infection about the importance of increasing fluids in the diet. What puts this client at a risk for not obtaining sufficient fluids?

Decreased ability to detect thirst Rationale: The sensation of thirst diminishes in those greater than 60 years of age; hence, fluid intake is decreased, and dissolved particles in the extracellular fluid compartment become more concentrated.

The nurse is administering a high dose of furosemide to a client with nephrotic syndrome. What potential complication is the nurse most concerned with for the client?

Electrolyte imbalance Rationale: Furosemide is a loop diuretic that can cause the excretion of potassium, sodium, and magnesium. The client receiving high doses should be monitored for electrolyte imbalance.

The nurse on the pediatric medical unit is admitting a school-age child from the emergency department. The child's chart entry reads: Progress Notes July 25, 20191445 Parent reports client has had no urine output for 18 hours. Bladder scan reveals 0 ml residual urine. Pulse 98/bpm and irregular; blood pressure 78/38 mmHg. Client reports abdominal pain described as 'cramps.' Bilateral muscle weakness noted. After reviewing the client's potassium level of 5.8 mEq/L (5.8 mmol/L), the nurse should anticipate an order for what intervention?

Administer sodium polystyrene as prescribed Rationale: client's presentation is consistent with acute kidney injury and accompanying hyperkalemia, which could be addressed with sodium polystyrene. Resolution of this life-threatening complication would be a priority. Inotropic medications like dobutamine are not indicated, and oral fluid intake would be insufficient. Intubation will not resolve the hyperkalemia.

A client in the intensive care unit has a critically low potassium level of 1.9 mEq/l (mmol/l). What would be the best way to replace this client's potassium?

Administer two potassium chloride 10 mEq (10 mmol) in 100 ml 0.9% sodium chloride IVPB, over 1 hour each Rationale: The nurse should administer two potassium chloride 10 mEq (10 mmol) in 100 ml 0.9% sodium chloride IVPB, over 1 hour each to safely and rapidly correct this client's potassium. IV potassium will be absorbed more fully and more quickly than oral potassium replacement. Potassium should never be given as an IV bolus, as it can result in severe cardiac dysrhythmias and sudden death. Sodium polystyrene is used in the treatment of hyperkalemia, and lowers potassium levels, so it is not indicated for this client.

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

Confusion and seizures Rationale: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit

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

Extreme anxiety Rationale: Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss

A client has a diagnosis of dehydration. What indicators would the nurse assess to determine an improvement in dehydration? Select all that apply.

Increased weight Increase blood pressure Lower pulse Increased skin turgor Rationale: The client with dehydration and risk for skin breakdown would need the weight assessed to determine an increase with improved fluid retention. An increased blood pressure and decreased, not increased, heart rate would indicate an improvement in fluid volume. The client's skin turgor would be increased, not decreased, with increased fluid intake as well

A full-term neonate is suspected of having hydrocephalus. The nurse collects what assessment finding to best assist in confirming the diagnosis?

Increasing occipital frontal circumference Rationale: Hydrocephalus is an increase in cerebrospinal fluid in the ventricles of the brain. The nurse should assess the infant's head circumference and note any increases. Hydrocephalus is associated with an increased occipitofrontal diameter. When palpated, the head has widened sutures with wide, open fontanels. Typically the fontanels will feel tense and bulging. Other, less specific signs of hydrocephalus include poor feeding, "setting sun" eyes, vomiting, lethargy, prominent veins, and seizure activity due to increased intracranial pressure. Meningitis can develop and result in fever

When caring for the neonate of a mother with gestational diabetes, which finding is most indicative of a hypoglycemic episode?

Jitterness Rationale: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl (2.2 mmol/L). A hyperalert state suggests neurologic irritability and isn't associated with blood glucose levels. A positive Babinski's reflex is a normal finding in neonates and isn't associated with hypoglycemia. A serum glucose level of 60 mg/dl (3.3 mmol/L) is a normal level

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Lightheadedness or paresthesia Rationale: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

What acid base imbalance is likely to occur in a patient who is on intermittent suction through an NG tube?

Metabolic alkalosis Rationale: Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning.

A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance?

Muscle weakness and weak, irregular pulse Rationale: The serum potassium level of 3.2 mEq/L is an indication of hypokalemia. Only 2% of the potassium is found in the extracellular fluid, and it is primarily responsible for neuromuscular activity. Muscle weakness and heart irregularities would be evident with hypokalemia. Potassium deficit is caused by diarrhea. Tetany and tremors are associated with hypocalcemia. Headaches and poor tissue turgor are associated with hyponatremia

Which symptom is an early indication that the client's serum potassium level is below normal?

Muscle weakness in the legs Rationale: An early indication of hypokalemia is muscle weakness in the legs. Potassium is essential for proper neuromuscular impulse transmission. When neuromuscular impulse transmission is impaired, as in hypokalemia, leg muscles become weak and flabby.

A child with diabetic ketoacidosis is being treated for a blood glucose level of 738 mg/dl (41.0 mmol/L). The nurse should anticipate an order for:

Normal saline with regular insulin Rationale: Short-acting regular insulin is the only insulin used for insulin infusions. Initially, normal saline is used until blood glucose levels are reduced, then a dextrose solution may be used to prevent hypoglycemia.

What acid base imbalance would be likely in a patient with myasthenia gravis?

Respiratory acidosis Rationale: Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.

What acid base imbalance would be likely in a patient experiencing myxedema coma?

Respiratory acidosis Rationale: The client's respiratory drive is depressed, resulting in alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and coma.