CH 13 - Fluid and Electrolyte Imbalance
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? "I will be sure to buy frozen vegetables when I grocery shop." "I will take a potassium supplement daily as prescribed." "A good breakfast for me will include milk and a couple of bananas." "I can use laxatives and enemas but only once a week."
"I can use laxatives and enemas but only once a week."
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? Confusion Hallucinations Headache Nausea
Confusion
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? "I'll drink cranberry juice with my breakfast instead of coffee." "I will not salt my food; instead I'll use salt substitute." "Bananas have a lot of potassium in them; I'll stop buying them." "I need to check to see whether my cola beverage has potassium in it."
"I will not salt my food; instead I'll use salt substitute." Explanation: The client should avoid salt substitutes. The nurse must caution clients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.
A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? 0.9% NaCl 0.45% NaCl 5% NaCl Lactated Ringer solution
0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.
A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? <136 mOsm/kg 350-544 mOsm/kg 275-300 mOsm/kg >408 mOsm/kg
275-300 mOsm/kg Explanation: In healthy adults, normal serum osmolality is 270 to 300 mOsm/kg (Crawford & Harris, 2011c).
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: 210 mOsm/kg. 280 mOsm/kg. 250 mOsm/kg. 230 mOsm/kg.
280 mOsm/kg. Explanation: Serum osmolality can be estimated by doubling the serum sodium or using the formula: Na × 2 = glucose/18 + BUN/3. Therefore, the nurse could estimate a serum osmolality of 280 mOsm/kg by doubling the serum sodium value of 140 mEq/L.
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A 72-year-old with a total knee repair A 52-year-old with diarrhea A 65-year-old with a myocardial infarction A 7-year-old with a fracture tibia
A 52-year-old with diarrhea
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution? Alkaline Neutral Basic Acidic
Acidic
A client reports 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 client's laboratory work has returned? Phosphorus Potassium Calcium Iron
Calcium Explanation: Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.
Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30 mm Hg; and HCO3, 21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state? Uncompensated respiratory alkalosis Compensated metabolic alkalosis Compensated metabolic acidosis Compensated respiratory alkalosis
Compensated respiratory alkalosis
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? Type 1 diabetes mellitus Myasthenia gravis Opioid overdose Extreme anxiety
Extreme anxiety Explanation: Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.
An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? Hyperkalemia Hypophosphatemia Hypokalemia Hypernatremia
Hypokalemia
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?
Increases arterial pH Explanation: Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.
The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? Magnesium Calcium Potassium Phosphorus
Magnesium Explanation: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis
A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant? Monitor for signs and symptoms of dehydration. Assess the client's weight daily for trends. Provide oral care every 2-3 hours. Teach the client about increased fluid intake.
Provide oral care every 2-3 hours. Explanation: Providing oral care for the client every 2-3 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? Temperature Blood pressure Pulse Respirations
Pulse
A patient in the ICU starts complaining of being "short of breath." An arterial blood gas (ABG) is drawn. The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? Metabolic alkalosis Respiratory alkalosis Respiratory acidosis Metabolic acidosis
Respiratory acidosis Explanation: The pH < 7.35 indicates acidosis. The PACO2 > 45 means this is respiratory acidosis, not metabolid acidosis. The HCO3 of 24 is normal, indicating that the respiratory acidosis is uncompensated.
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? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis Explanation: 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.
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)? A frozen, packaged low-fat dinner with a side salad Tomato juice, low-fat cottage cheese, and three slices of bacon Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Three ounces of sliced ham, beets, and a salad
Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad
A client with hypervolemia asks the nurse by what mechanism the sodium-potassium pump will move the excess body fluid. What is the nurse's best answer? Passive elimination Free flow Active transport Passive osmosis
active transportExplanation:Active transport is the physiologic pump that moves fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate for energy. Passive osmosis does not require energy for transport. Free flow is transport of water naturally. Passive elimination is a filter process carried out in the kidneys.
A client with emphysema is at a greater risk for developing which acid-base imbalance? chronic respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis
chronic respiratory acidosis Explanation: 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.
Early signs of hypervolemia include moist breath sounds. increased breathing effort and weight gain. thirst. a decrease in blood pressure.
increased breathing effort and weight gain. Explanation: Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.
A 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 acid-base imbalance? metabolic acidosis metabolic alkalosis respiratory acidosis respiratory alkalosis
metabolic alkalosis Explanation: Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The client's regular use of baking soda (sodium bicarbonate) may create a risk for this condition. Metabolic acidosis refers to decreased plasma pH because of increased organic acids (acids other than carbonic acid) or decreased bicarbonate. Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary with expired air.
A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching? polyuria flank pain tingling sensation in the fingers hypertension
tingling sensation in the fingers
A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? intake and output weight edema vital signs
weight Explanation: Daily weight provides the ability to monitor fluid status. A 2-lb (0.9 kg) weight gain in 24 hours indicates that the client is retaining 1 L of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output do not account for unexplainable fluid loss.
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 L 1500 ml 1250 ml 500 ml
1 L Explanation: A 2-lb weight gain in 24 hours indicates that the client is retaining 1L of fluid.
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A 65-year-old with a myocardial infarction A 7-year-old with a fracture tibia A 72-year-old with a total knee repair A 52-year-old with diarrhea
A 52-year-old with diarrhea Explanation: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Flaccidity and thirst Confusion and seizures Sunken eyeballs and spasticity Tetany and increased blood urea nitrogen (BUN) levels
Confusion and seizures Explanation: 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. Spasticity, flaccidity, and tetany are unrelated to water intoxication.
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. Administer IV bicarbonate. Compare ABG findings with previous results. Suction the client's airway. Document presenting signs and symptoms. Maintain intake and output records.
Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Explanation: Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Bradycardia Crackles in the lung fields Decreased blood pressure Shortness of breath Distended neck veins
Distended neck veins Crackles in the lung fields Shortness of breath Explanation: Clinical manifestations of FVE (hypervolemia) include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Subnormal temperature Low heart rate Elevated blood pressure Rapid respiration
Elevated blood pressure Explanation: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum blood urea nitrogen (BUN) level of 8.6 mg/dl Hematocrit of 52% Serum sodium level of 124 mEq/L Serum creatinine level of 0.4 mg/dl
Serum sodium level of 124 mEq/L Explanation: 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. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.
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 7.50 7.35 7.45 7.30
Explanation: The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is >7.45 and the PaCO2 is <38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, gram-negative bacteremia, and inappropriate ventilator settings.
The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? A 79-year-old client admitted with a diagnosis of pneumonia. An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift. A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet.
a) An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide The 82-year-old client has three risk factors: advanced age, tube feedings, and diuretic usage (torsemide). This client has the highest risk for fluid and electrolyte imbalances. The 45-year-old client has the risk factor of surgery, the 79-year-old client has the risk factor of advanced age, and the 66-year-old client has the risk factors of age and the bile drain, but none of these are the client at the highest risk.
A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse? renin-angiotensin-aldosterone system bicarbonate-carbonic acid buffer system sodium-potassium pump ADH-ANP buffer system
bicarbonate-carbonic acid buffer system Explanation: The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system. The renin-angiotensin-aldosterone system regulates blood pressure. The sodium-potassium pump regulate homeostasis. The ADH-ANP buffer system regulates water balance in the body.
A nurse evaluates a client's laboratory results. What is a factor that may be affecting an increase in serum osmolality? free water loss diuretic use hyponatremia overhydration
free water loss Osmolality measures the solute concentration per kilogram in blood and urine. Water loss in the serum would increase the solute concentration. Free water loss is a factor increasing serum osmolality. Diuretic use, overhydration, and hyponatremia are factors decreasing serum osmolality.
The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be which of the following? a) 145 mEq/L b) 155 mEq/L c) 125 mEq/L d) 135 mEq/L
b) 155 mEq/L Explanation: The patient is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.
A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values:Sodium 134 mEq/L (134 mmol/L)Potassium 3.2 mEq/L (3.2 mmol/L)Chloride 111 mEq/L (111 mmol/L)Magnesium 1.1 mg/dL (0.45 mmol/L)Calcium 8.4 mg/dL (2.1 mmol/L)What fluid and electrolyte imbalance would the nurse relate to the client's findings? hyponatremia hypokalemia hypomagnesemia hypocalcemia
hypomagnesemia Explanation: Magnesium, the second most abundant intracellular cation, plays a role in both carbohydrate and protein metabolism. The most common cause of this imbalance is loss in the gastrointestinal tract. Hypomagnesemia is a value less than 1.3 mg/dL (0.45 mmol/L). Signs and symptoms include muscle weakness, tremors, irregular movements, tetany, vertigo, focal seizures, and positive Chvostek's and Trousseau's signs.
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: diaphoresis. constipation. tremors. muscle weakness.
muscle weakness. Explanation: Muscle weakness; bradycardia; nausea; diarrhea; and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.
Which set of arterial blood gas (ABG) results requires further investigation? pH 7.35, PaCO2 40 mm Hg, PaO2 91 mm Hg, and HCO3- 22 mEq/L pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L pH 7.38, partial pressure of arterial carbon dioxide (PaCO2) 36 mm Hg, partial pressure of arterial oxygen (PaO2) 95 mm Hg, bicarbonate (HCO3-) 24 mEq/L pH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, and HCO3- 26 mEq/L
pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L Explanation: The ABG results pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L indicate respiratory alkalosis. The pH level is increased, and the HCO3- and PaCO2 levels are decreased. Normal values are pH 7.35 to 7.45; PaCO2 35 to 45 mm Hg; HCO3- 22 to 26 mEq/L.