326 exam #3
F&E secondary prevention
- no screening for f&e imbalance is routine for the general population - monitoring serum blood electrolyte levels may be part of disease management
what are two key electrolytes
- potassium - calcium
electrolyte imbalances
- potassium, calcium, and magnesium
what to monitor for IV fluids?
- rate - IV site - edema/cough - crackles/volume overload
caution use with thiazide and loop diuretics
- renal disease - diabetes - pregnancy
IV fluids general precautions
- renal/cardiac disease - head injuries
loop diuretic only s/e
ototoxicity
what are potassium sparing diuretics contraindicated with?
HYPERkalemia
What are loop and thiazide diuretics contraindicated with?
HYPOkalemia
Chvostek's sign
Hypocalcemia (facial muscle spasm upon tapping)
electrolyte imbalance assessment
focused on patient need or specific concern
caution use with potassium sparing diuretics
- medications which RAISE potassium - renal disease - pregnancy - diabetes
WBC range
4.5-10.5
potassium functions (high vs. low)
cardiac function - dysrhythmias and arrest (bradycardia arrest) with high - muscles become more flaccid with low
diuretic types
- loop - thiazide - potassium sparing
diuretics assessment
- BP - HR - Daily weight - labs (K+)
what do you monitor with Kayexalate
- GI output - potassium level
F&E pharmacotherapy
- IV fluids - blood and blood products Diuretics - loops - thiazide - potassium sparing - osmotic Kayexalate
Fluid Volume Excess (FVE)
- Too much volume - SOB - Blurred vision - Alteration characterized by the abnormal retention of fluids and electrolytes in an isotonic fashion.
Kayexalate - assessment
- cardiac assessment labs: - potassium
diagnostic tests
- complete metabolic panel - osmolality - CBC (RBC, Hgb, Hct) - type and crossmatch - electrocardiogram (ECG)
diuretic medication interactions
- concurrent insulin use (may need to adjust dose, decreased potassium levels) - digoxin (decreased potassium = increased risk of toxicity) - lithium (decreased sodium = increased risk of toxicity) - ototoxic drugs (loops) - NSAIDS (nephrotoxic) - HTN meds (decreased BP)
hypertonic iv fluids and when would you use them
- draws the H2O in the cell toward the fluid - dehydrates cells/tissues - super rare to give 3% saline - if you have severely low sodium this could help - head injuries (reduces swelling) - increased ICP - severe low sodium levels (Na+)
what if we give too much total volume> how will we know?
- edema - crackles
how can fluid and electrolyte imbalances occur
- fluid imbalance - osmolality imbalances - electrolyte imbalances - blood loss
IV fluids side effects
- fluid/volume overload - electrolyte imbalance
potassium sparing diuretic s/e
- hyperkalemia - anti-androgen effects (monitor for changes adverse effects)
crystaloid iv fluids and tonicity
- hypertonic - isotonic - hypotonic has to do with concentration of the fluid and H2O movement
loop and thiazide diuretics side effects/rare SE
- hyponatremia - hypotension - dehydration - hypokalemia rare: - hyperglycemia
consequences of F&E imbalance
- impaired perfusion - impaired gas exchange/oxygenation - impaired cerebral function - impaired neuromuscular function
fluid and electrolyte attributes
- intake and output - fluid compartments (where us it?) - osmolality
IV fluids assessment
- intake and output - daily weight - ambulation, LOC? - skin turgor - edema - blood pressure, HR/pulse, lung cardiac assessments - tonicity
what do you do if a blood transfusion reaction occurs
- stop the transfusion and notify the physician - change IV tubing - treat symptoms
diuretic uses relating to F&E
- treating HTN - commonly first line - edema, and pulm edema - heart failure symptoms (fluid overload) - to counteract potassium loss (potassium sparing)
blood transfusion assessments
- type and cross match - informed consent signed
fluid and osmolality assessment
- urine color - I's and O's - edema - skin turgor - cap refill/pulse - appearance/touch - LOC - fontanel sunken - mucous membranes - lungs --> crackles
how much normal saline can be run through prime tubing with blood products?
0.9%
platelet range
1.4-4.0
magnesium range
1.8-2.6 mEq/L
Hemoglobin range
12-17.4
sodium range
135-145 mEq/L
how many RNs need to check blood prior to admin?
2
albumin range
3.4-5.4 g/dL
Potassium range
3.5-5.2 mEq/L
RBC range
3.6-5.4
Hematocrit range
36-48%
Whole blood consists of
55% plasma and 45% formed elements Erythrocytes (RBC) Leukocytes (WBC) Platelets
calcium range
8.5-10.2 mg/dL
A patient has been on spironolactone for five years and is getting an EKG at their primary care provider after feeling lightheaded recently. Which of the following findings would be unexpected based on the history? a. Flat T Waves b. Potassium level of 5.6 c. Diarrhea d. Cardiac dysrhythmias
A - Long-term Spironolactone puts a patient at risk for hyperkalemia since it is a potassium sparing diuretic. Therefore you would expect to see normal findings of hyperkalemia in this patient.
Which of the following is the best indicator that Kayexalate has achieved the desired effect? a. Potassium of 3.8 b. Potassium of 3.4 c. 5 stools in 3 hours d. ECG shows peaked T waves
A - The desired effect of Kayexalate is to decrease potassium into the normal range (between 3.5 and 5.2), not to induce defecation.
A patient with a potassium level of 3.1 has been taking Furosemide daily. Which medication will the nurse anticipate the patient being switched to? a. Starting spironolactone b. Starting hydrochlorothiazide c. Increasing furosemide d. No change is indicated
A - The patient is experiencing hypokalemia as a result of taking a potassium wasting diuretic daily.
You are providing education to a patient with a new diagnosis of heart failure who is newly prescribed Furosemide. Which of the following patient statements demonstrates a need for further teaching about Furosemide? a. "I should buy a scale and take my weight every other day" b. "I should sit at the edge of my bed before changing positions" c. "I should eat potassium-rich foods like bananas and potatoes" d. "If I notice new onset shortness of breath at rest, I need to call my provider right away"
A - This patient needs further teaching because heart failure patients need to take their weights DAILY in order to notice any symptoms of worsening heart failure. Taking daily weights is one of the most important interventions for clients with HF because even a 2-3lb change in weight can indicate FVE which can have a lot of consequences for HF clients.
Which of the following medication combinations can potentially lead to hypokalemia? SATA a. Furosemide and hydrochlorothiazide b. Insulin and furosemide c. Spironolactone and lisinopril d. Digoxin and hydrochlorothiazide e. Propranolol and hydrochlorothiazide
A and B - Furosemide and hydrochlorothiazide both drop potassium levels, so taking them concurrently increases the risk of developing hypokalemia. Insulin decreases potassium because it draws potassium into the cells.
You are instructed to give your patient a bolus of isotonic fluids, you understand which options could be appropriate? SATA a. Lactated Ringers b. 0.45% NS c. 3% NS d. 0.9% NS
A and D
Trousseau's sign
A sign of hypocalcemia . Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.
A patient came in with hypernatremia and peaked t waves on their EKG. What food would you suggest they stay away from? SATA a. Cured meats b. Milk c. Packaged foods d. Salt substitute e. Nuts
A, B, C, D - A,B,C are all high in sodium and would increase their serum Na levels. While D does not have sodium in it, the substitute is potassium chloride and the pt has peaked t waves which would indicate a possibility of high potassium levels so we would not want them to have salt substitutes either. Nuts are okay.
A patient has a potassium level of 2.7. What food would you include for them to eat in their discharge teaching? SATA a. leafy greens b. Bananas c. Canned salmon d. Chocolate e. Watermelon
A, B, E
A new nurse is caring for a patient receiving a blood transfusion. Which of the following assessment findings may indicate to the nurse that the patient is experiencing a transfusion reaction? SATA a. Chills and a temperature of 99.9º F b. Decrease in BP from 110/75 to 80/52 c. Diarrhea d. Decrease in HR from 70 to 55 BPM e. Lower back aches
A, B, E - Transfusion reaction symptoms can include low back pain, hypotension, tachycardia, fever and chills, hives or rashes, cyanosis, shaking, N/V, and eventual renal failure.
A patient is being treated for a heart failure exacerbation. Which of the following symptoms does the nurse expect to see? SATA a. Decreased urine output b. Weight loss of 3 lbs in the past 2 days c. Lower extremity edema d. Dyspnea only with exertion e. Crackles in the lower lobes of the lung
A, C, and E - An exacerbation of heart failure means that the patient's cardiac output is not sufficient and is not adequately perfusing their body. E is correct because the backup of fluid with cause crackles to be heard in the lungs. C is correct because fluid will become trapped in the body's tissues due to the heart not being strong enough to adequately circulate blood. A is correct because the decreased perfusion to the kidneys will cause the urine output to decrease.
A nurse is preparing to administer 3% NS to one of their patients and is wondering if this IV fluid will be safe to administer to their patient. Which of the following patients would the nurse expect this IV fluid to be given to? a. A patient with severe hypovolemia and dehydration. b. A patient that was just admitted for a traumatic head injury. c. A patient that is hypokalemic. d. A patient experiencing fluid volume excess due to heart failure exacerbation.
B - 3% NS is a HYPERtonic, meaning that its osmolality is greater than what it is in the blood. When hypertonic fluids are administered, they will draw fluid from interstitial spaces back into the vasculature. This would be important in a patient with a head injury to bring fluid from their cranial spaces due to inflammation back into the vasculature to help decrease the amount of pressure being put onto their brain.
A patient's lab results came back: RBC (4.0); Sodium (143); Potassium (5.7); Calcium (8.2); Magnesium (2.2). Based on these lab results, which one of the following signs/symptoms should the nurse suspect to see in the patient? a. Increased thirst and confusion b. Dysrhythmia and peaked T waves c. Bone pain and constipation d. Fatigue and heart palpitations
B - All the lab values are normal except for the potassium level. The patient has hyperkalemia, which can lead to signs/symptoms such as dysrhythmia and peaked T waves.
On assessment, the nurse notices a patient receiving an IV bolus is short of breath, has crackles in their lungs and a bounding HR, and is confused. Which of the following is the priority nursing intervention for this patient? a. Have the patient turn, cough, and deep breathe b. Stop the IV infusion c. Assess the patient's vital signs d. Reposition the patient with their legs elevated
B - The patient is displaying signs of fluid volume overload and pulmonary edema.
A nurse is administering a packed RBC transfusion to a 60 year old patient with type B+ blood. Which of the following blood types would the nurse question transfusing? a. B- b. AB+ c. O- d. B+
B - Type AB blood is not compatible with Type B blood, so the nurse should hold an AB+ blood transfusion. Patients with type B blood can safely receive Type B or Type O blood. Remember that patients with a positive Rh factor can safely receive either positive or negative blood transfusions.
A patient comes into the ED after excessive fluid loss from vomiting and diarrhea. Which manifestations may the patient present with? Select all that apply. a. Crackles in the lungs b. HR of 146 c. Pulse strength of 4+ d. HCT of 51%, HgB of 19.6 e. Oliguria
B, D, E - Hallmark manifestations in patients with fluid volume deficit include tachycardia, hypotension, poor skin turgor, oliguria (abnormally small amounts of urine), dry skin, potential weight loss, headache/dizziness, orthostatic hypotension, and elevated hemoglobin and hematocrit levels.
A patient is receiving 2 units of packed red blood cells. Which of the following symptoms would you report as a transfusion reaction? SATA a. Upper back pain b. Fever and chills c. Hypertension d. Tachycardia e. hives/rash
B, D, E - flush with saline, and call the provider.
A patient with hypocalcemia is being admitted to your med-surg floor. Which finding would you likely observe while conducting an admission assessment? a. Calcium level of 10.1 b. Increased nausea and vomiting c. A positive chvostek sign d. Decreased muscle reflexes
C - Common findings of hypocalcemia would be a Ca2+ level of less than 8.2, increased muscle reflexes, tetany, decreased HR & BP, brittle bones, and a positive Chvosteks and Trousseau's sign.
Decreased oncotic pressure and increased hydrostatic pressure is most likely to occur in which state? a. Any fluid volume imbalance b. Fluid volume deficit c. Fluid volume excess d. Fluid volume within normal limits
C - Hydrostatic pressure is the pushing of fluid out of the capillaries while oncotic pressure is the pulling of fluid back into the capillaries. If the oncotic pressure is weaker than the hydrostatic pressure, then fluid will not get adequately pulled back into the capillaries. This can result in fluid accumulating in the tissues, which can lead to fluid volume excess.
A patient is presenting with a thready and weak pulse of 58, and decreased bowel tones. In addition, the patient has been having frequent episodes of vomiting and nausea and is taking hydrochlorothiazide. Which of the following findings would explain the patient's condition? a. Potassium level of 7.0 b. Potassium level of 3.5 c. Potassium level of 2.4 d. None of the options are correct
C - Potassium level of 2.4. Hydrochlorothiazide is a potassium wasting diuretic. Symptoms of hypokalemia include bradycardia and decreased bowel tones.
A nurse is assigned a new patient with cerebral edema and is reviewing the patient's orders. Which of the following orders would the nurse question? a. D5LR IV solution b. 3% NaCl saline solution c. 0.45% NaCl solution d. Continuous mental status assessment
C - The nurse should question an order for 0.45% NaCl because it is a hypotonic solution that is contraindicated for patients with cerebral edema since it increases the hydration of cells and can worsen edema.
A patient is receiving hydrochlorothiazide for their hypertension. What statement by the patient indicates that teaching was effective? a. "I will have increased sodium levels so I should cut back on my salt intake" b. "I may experience anti-androgen effects with this medication" c. "I may experience hypotension and dehydration so I should drink lots of water and stand up slowly" d. "I may experience ringing in my ears as a sign of ototoxicity"
C - While taking hydrochlorothiazide the patient may experience dehydration and hypotension as a result of the water loss, they may experience orthostatic hypotension and should be advised to change positions slowly in order to allow the body to adjust slower.
You are preparing to administer Spironolactone for a client with acute exacerbations of HF. Which of the following assessment findings would cause you to HOLD the dose? a. BP of 120/82 (PT's baseline BP is 125/80) b. K level of 3.7 c. Bounding pulse d. K level of 5.5
D - Spironolactone is a K+-sparing diuretic which means it retains K+. The contraindications for this medication is hyperkalemia. A client who's K level is at 5.5 indicates that they are already in a state of hyperkalemia, so you would hold this dose in order to prevent further complications.
Which of the following statements by a new nurse indicates further teaching regarding blood transfusions is required? a. "If I notice a transfusion reaction occurring, I should immediately stop the transfusion and notify the patient's provider, then change the IV tubing, and then treat symptoms." b. "Two RNs are required to check blood transfusions before they are administered." c. "It is common for patients to receive transfusions of packed RBCs, fresh frozen plasma, platelets, or albumin rather than whole blood." d. "Most reactions to blood transfusions will occur between 12-24 hours after the transfusion finishes."
D - The majority of transfusion reactions occur during or right after a transfusion - not later on. The first steps are to STOP the transfusion and notify the provider (often simultaneously in a clinical setting), and then change the IV tubing and then treat symptoms.
The physician prescribes a patient hydrochlorothiazide. The nurse knows that this diuretic with help the patient by... a. Interfering with water and sodium reabsorption from the proximal and distal tubules, as well as the loop of Henle b. Trapping potassium in the GI tract for excretion c. Blocking the action of aldosterone d. Blocking reabsorption of NaCl in the early distal convoluted tubule
D - Thiazides block the reabsorption of Na/Cl. - NOTE TO STUDENTS THAT IT WILL NOT BE ON THE TEST!
Osmosis
Diffusion of water through a selectively permeable membrane
2nd fluid spacing
Edema, extra fluid in interstitial space.
sodium polystyrene sulfonate name and function
Kayexalate - traps K+ in the GI tract for excretion --- used to lower serum potassium levels - given PO or PR
Fresh frozen plasma
Liquid portion of whole blood is separated from cells and frozen
Diffusion
Movement of molecules from an area of higher concentration to an area of lower concentration.
1st fluid spacing
Normal distribution of fluid in ICF and ECF
Kayexalate route
PO or PR
Electrocardiogram (ECG)
T wave changes! T wave is more peaked with hyperkalemia
hydrostatic pressure
The pressure of water against the walls of its container.
oncotic pressure
The pressure of water to move, typically into the capillary, as the result of the presence of plasma proteins.
What does a type and cross match indicate?
Whether the client's blood and donor blood are compatible.
The nurse is reviewing laboratory values for a patient suspected of having a fluid imbalance. Which laboratory value should indicate a diagnosis of dehydration to the nurse? a. hematocrit 53% b. hemoglobin 13.5 g/dL c. serum potassium 3.8 mEq/L d. serum sodium 144 mEq/L
a
You are caring for a patient receiving an infusion of 0.45% NS. Which assessment finding is more concerning? a. decreased LOC b. urine output 80ml/hr c. +1 pitting edema d. serum sodium 133 mEq/L
a
Which of the following nursing actions are appropriate for a patient experiencing a post-partum hemorrhage (Select all that apply) a. lay patient down b. sit the patient up c. massage the fundus d. administer packed red blood cells e. administer 0.45% NS
a, c, and d
diuretic common off label uses (not related to F&E)
ability to block testosterone - potassium sparing have anti androgen properties - used to help correct hormonal imbalances or support gender affirming care ---> if wishing to decrease effects of androgens
A client with lower extremity edema and excess fluid in the lungs has been discharged home with the medication furosemide. For this client, which finding is the best indicator that the medication is working effectively: a. high urine output b. consistent daily weight c. blood pressure in normal range d. normal potassium level
b
A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding? a. "dehydration is only a problem in the summer months when it's hot outside" b. "i should drink more water when i feel thirsty or becoming irritable" c. "if my skin becomes dry and itchy I can apply extra lotion" d. "vitamin hydration drinks would be good when i feel my heart pounding and become light headed"
b
The nurse is caring for a patient with a positive Chvostek's sign. Which electrolyte imbalance is the patient likely experiencing? a. hypermagnesemia b. hypocalcemia c. hypkerkalemia d. hypochloremia
b
Which of the following nursing actions is the priority for a patient experiencing a potential transfusion reaction? a. administer epinephrine b. stop the transfusion c. apply oxygen d. re-type and crossmatch
b
The nurse is reviewing a patients complete blood count (CBC) following the administration of 2 units packed red blood cells. The nurse anticipates which values will have changed as a a result of that administration: a. platelets b. Hct c. WBC count d. RBC count e. Hgb
b, d, and e
Which of the following statements regarding dietary teaching is accurate (Select all that apply) a. fluid restrictions only count free water b. bananas are a source of potassium c. salt substitutes are safe for any diet d. cutting table salt from the diet is sufficient for sodium retention e. grains are source of magnesium
b and e
when would you perform a type and crossmatch diagnostic test
before you transfuse someone
Platelets
blood clotting
If someone is Rh positive can they receive positive or negative blood transfusions
both
colloids vs crystalloids
colloids- used to replace a specific part of blood that may be deficient crystalloids- attempt to replace volume
osmolality diagnostic test
concentration (take blood, serum ...)
osmolality imbalances
concentration hyper/hypo natremia - overhydration and dehydration - SODIUM
what should you continuously monitor with kayexalate?
continuous cardiac monitoring - want to know k+ values - peaked t wave started --> should go back to normal
do we primarily use crystalloids or colloids?
crystalloids
A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day? a. correcting the associated dehydration b. preventing increased sodium levels c. limiting interaction between drugs d. maintaining serum potassium levels
d
Which breakfast diet would you recommend to a patient that has a magnesium level of 1.3? a. Milk, vanilla yogurt, and smoothies with dark leafy greens b. Bacon breakfast burrito and applesauce c. Oatmeal with bananas, cantaloupe, and orange juice d. Peanut butter whole grain toast and oatmeal with almonds
d -he patient has a magnesium level below 1.8 which makes them hypomagnesemic. It is important to educate the patient on incorporating more magnesium into their diet. Foods high in magnesium include avocados, spinach, dark chocolate, nuts, and legumes.
IV fluids contraindications
depends on the fluid and patient condition
Kayexalate s/e
diarrhea
blood transfusion evaluation
did the med do what it was supposed to? - lab perfusing/oxygenation activity
kayexalate evaluation
did the medication do what it was supposed to do? (lower potassium level)
3rd fluid spacing
fluid where normally isn't any - abdominal cavity, bowel, fluid is not available for circulation
what does a t wave look like with hypokalemia
flat
IV fluid risks
fluid overload - depends on fluid AND rate of infusion
what effects are there from the different osmolalities?
fluid shifts
loop diuretic name, what does it do
furosemide (lasix) - potassium wasting - most powerful diuretics !!!!!! - increased H2O loss - increased sodium loss - increased potassium loss - increased UO
thiazide name and function
hydrochlorothiazide - block reabsorption of Na/Cl - increased H2O loss - increased sodium loss - increased potassium loss - increased UO
what type of iv fluid would you give for a head injury? and why
hypertonic fluid --> will decrease swelling
Packed Red Blood Cells (PRBCs)
increase oxygen carrying capacity of blood
How does insulin affect the Na/K pump and serum K+ levels
it increases the action of the Na/K pump and lowers serum K+
fluid and electrolyte risk factors
lifespan: - infants and children - older adults there can be many causes for imbalances
what is an example of when phosphorous would be given
low in chronic kidney disease
what is an example of when magnesium would be given
may be given in pregnancy to slow labor
colloid
milk mixed with water - cloudy - H2O - electrolytes - protein - expensive - more monitoring
do electrolyte imbalances happen on their own?
most do not -- commonly co occur
what is most notable osmolality imbalances and where is it located
most notable impact is on the brain - drowsy - confused - agitated - restless - decreased LOC - increased risk of seizure - sodium level
Calcium function in the body (high vs. low)
muscles - more excited and reactive when low - less excited and reactive when high - reflexes, bowels heart
would iv fluids help with renal failure?
no bc you do not make urine well so you could cause a fluid overload w an iv
would iv fluids help with heart failure pts ?
no, fluids wont help with pumping
isotonic iv fluids and when would you use them
normal - increased blood volume Normal saline 0.9% Lactated Ringers ---- could help with BP ---- not a lot of fluid shift - blood loss - surgery - septic shock --> want to improve their perfusion (will increase BP)
what does a t wave look like with hyperkalemia
peaked
albumin colloid solution
plasma protein
what do we want to always consider with insulin
potassium levels
F&E primary prevention
prevention is designed to minimize risk factors and manage the disease - patient teaching - dietary measures - fluid management - safety - nutrition/hydration (what foods have electrolytes) - fluid management - safety
would IV fluids help with a PE?
probably not
crystalloid
salt dissolved in water - leaky blood vessels
Potassium sparing diuretics name and function
spironolactone (aldactone) - blocks action of aldosterone - increased H2O loss - increased sodium loss - decreased potassium loss - increased UO
is bicarb and electrolyte?
technically, yes
osmolality
the concentration of solutes in body fluids
Fluid and Electrolytes definition
the process of regulating fluid volume across compartments, body fluid distribution, and electrolyte concentration
crystalloid challenge
they're just water + electrolytes - can easily leave blood vessels
what to monitor with blood transfusions/what will you see
transfusion reaction - low back pain - hypotension - tachycardia - fever and chills - hives/rashes - cyanosis - shaking - N/V - leading to renal failure
F&E collaborative interventions
treatment strategies depend on the underlying conditions ex. banana --> muscle cramps treat the symptoms -- vomiting/diarrhea, and replace fluid loss fluid replacement therapy -- oral fluids, intravenous fluids - electrolyte supplements and replacement (food) - blood/blood product transfusion - dietary education -- disease and treatment specific
what can insulin be used to treat/routes
treats hyperkalemia routes: - SubQ or IV
what can insulin be paired with and why
usually paired with D10 or D50 to avoid hypoglycemia
fluid imbalances (ECV)
volume problems - fluid volume excess and fluid volume deficit
hypotonic iv fluids and when would you use them
water into cell - rehydrating 1/2 normal saline (0.45%) ----- big risk of edema dextrose 5% in water (D5W) - diabetic ketoacidosis - water replacement
