Ch. 13 Fluid, Electrolytes: Balance and Disturbances

Clinical manifestations of hypernatremia?

-Dehydration -thirst p. 267-268

Interventions for metabolic acidosis?

-Give back bicarbonate if there is a bicarb deficiency, give back potassium if potassium is deficient, -Sodium bicarbonate for K+ on the heart p. 285

Clinical manifestations of hyponatremia with water gain and Na+ loss?

-anorexia -muscle cramps -exhaustion p. 265

Clinical manifestations of hyponatremia?

-poor skin turgor -dry mucosa -headache -decreased salivation -orthostatic decreased blood pressure -nausea/vomiting -abdominal cramping -neurological changes (altered mental status, status epilepticus, coma, cerebral edema) p. 265

Clinical manifestations of hypercalcemia on EKG?

Abnormal ST and QT intervals, bradycardia, heart blocks p. 273

Interventions for metabolic alkalosis?

Correct I&O. Give fluids. Sodium chloride fluids, (0.9%NS) Cimetidine (Tagamet) to reduce HCl p. 286

Clinical manifestations of hypokalemia on an ECG?

Flattened T waves Prominent U waves ST depression Prolonged PR interval p. 269

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? Intracellular fluid Extracellular fluid Interstitial fluid Intravascular fluid

Intracellular fluid Explanation: About 60% of the adult human body is water. Most body water is located within the cell (intracellular fluid). Due to several physiological changes of aging, geriatric clients have less bodily fluids. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Antidiuretic Hormone and Thirst, p. 257.

Clinical manifestations of hypoMg on ECG?

PVC Flat or inverted T waves Depressed ST segment Prolonged PR Widened QRS p. 277

Clinical manifestations of hyperMg on ECG?

Prolonged PR and QRS Peaked T waves p. 277

Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis? Sodium bicarbonate Magnesium sulfate Furosemide Calcium gluconate

Sodium bicarbonate Explanation: IV administration of sodium bicarbonate may be necessary in severe metabolic acidosis to alkalinize the plasma, shift potassium into the cells, and furnish sodium to antagonize the cardiac effects of potassium. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 272.

A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? vital signs edema intake and output weight

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Detecting and Controlling Hypervolemia, p. 264.

Which condition might occur with respiratory acidosis? Increased intracranial pressure Decreased blood pressure Decreased pulse Mental alertness

Increased intracranial pressure Explanation: If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 286.

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. Crackles on auscultation Cyanosis Hypertension Shoulder pain Dyspnea Tachycardia

Cyanosis Shoulder pain Dyspnea Tachycardia Explanation: Hypotension, along with the other correct choices, is a manifestation of an air embolism. Crackles on auscultation is a major indicator of circulatory system overload. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, Air Embolism, p. 291.

Clinical manifestations of hypokalemia?

Fatigue anorexia N/V muscle weakness polyuria (hyperaldosterone) decreased bowel motility ventricular asystole or fibrillation paresthesias leg cramps decreased BP hypoactive reflexes p. 269

Clinical manifestations of hyperkalemia?

Muscle weakness tachycardia to bradycardia dysrhythmias flaccid paralysis paresthesias intestinal colic cramps abdominal distention irritability anxiety p. 269

Clinical manifestations of hypercalcemia?

Muscular weakness Constipation anorexia N/V polyuria and polydipsia dehydration hypoactive deep tendon reflexes lethargy deep bone pain pathologic fractures flank pain calcium stones HTN p.273

Clinical manifestations of hyperkalemia on an ECG?

Tall tented T waves Prolonged PR interval and QRS Absent P waves ST depression p. 269

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: metabolic acidosis. metabolic alkalosis. respiratory acidosis. respiratory alkalosis.

respiratory alkalosis. Explanation: This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 287.

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply. An elevated hematocrit level A low urine specific gravity Electrolyte imbalance Low protein level in the urine Absence of ketones in urine

An elevated hematocrit level Electrolyte imbalance Explanation: Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Laboratory Tests for Evaluating Fluid Status, p. 255.

When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highestpriority for the nurse to follow up? Irregular heart rate Weight loss of 4 lb Mild confusion Blood pressure 96/53 mm Hg

Irregular heart rate Explanation: Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, confusion may occur with dehydration and hyponatremia, and blood pressure is slightly lower than normal (though not life threatening); in each case, following up on potential cardiac dysrhythmias is a higher priority. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Electrolyte Imbalances, p. 264.

Clinical manifestations of hypoMg?

Neuromuscular irritation +Trosseau and Chvostek insomnia mood changes anorexia vomiting increased tendon reflexes HTN p. 277

Clinical manifestations of hypocalcemia?

Tetany Numbness/paresthesia Positive Trosseau and Chvostel sign Carpopedal spasms Hyperactive deep tendon reflexes irritability bronchospasm anxiety impaired clotting time decreased thrombin diarrhea decreased BP p. 273

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. Drink at least eight glasses of fluid each day. Drink caffeinated beverages to retain fluid. Drink carbonated beverages to help balance fluid volume. Drink water as an inexpensive way to meet fluid needs. Respond to thirst

Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst Explanation: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Medical Management, p. 260.

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

The client had a liver transplant 2 years ago. Explanation: A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Chart 23-7, p. 600.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Table 13-5, p. 261.

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 500 ml 1500 ml 1250 ml

1 L Explanation: A 2-lb weight gain in 24 hours indicates that the client is retaining 1L of fluid.

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

115 mEq/L Explanation: Features of hyponatremia associated with sodium loss and water gain include anorexia, muscle cramps, and a feeling of exhaustion. The severity of symptoms increases with the degree of hyponatremia and the speed with which it develops. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, Sodium Deficit (Hyponatremia), p. 265.

At which serum sodium concentration might convulsions or coma occur? 130 mEq/L (130 mmol/L) 145 mEq/L (145 mmol/L) 140 mEq/L (140 mmol/L) 142 mEq/L (142 mmol/L)

130 mEq/L (130 mmol/L) Explanation: Normal serum concentration level ranges from 135 to 145 mEq/L (135-145 mmol/L). When the level dips below 135 mEq/L (135 mmol/L), hyponatremia occurs. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L (mmol/L) are within the normal range. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Table 13-6, p. 265.

A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client? 110 mEq/L 130 mEq/L 145 mEq/L 165 mEq/L

165 mEq/L Explanation: The normal sodium level is 135- 145 mEq/L (135-145 mmol/L). In hypernatremia, the serum sodium level exceeds 145 mEq/L (145 mmol/L) and the serum osmolality exceeds 300 mOsm/kg (300 mmol/L). The urine specific gravity and urine osmolality are increased as the kidneys attempt to conserve water (provided the water loss is from a route other than the kidneys). Body temperature may increase mildly, but it returns to normal after the hypernatremia is corrected. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Hypernatremia, p. 267.

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. 230 mOsm/kg. 250 mOsm/kg. 280 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 255.

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? 11 mEq/L 5 mEq/L 2 mEq/L 1 mEq/L

5 mEq/L Explanation: Magnesium excess (>2.7 mEq/L) is associated with the following symptoms: flushing, hypotension, muscle weakness, drowsiness, hypoactive reflexes, depressed respirations, and cardiac arrest. The respiratory center is depressed when serum magnesium levels exceed 10 mEq/L (5 mmol/L). This is not present in this patient, so the magnesium level is unlikely to be 11 mEq/L. Coma, atrioventricular heart block, and cardiac arrest can occur when the serum magnesium level is greatly elevated and not treated. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Magnesium Imbalances, p. 276.

What percentage of potassium excreted daily leaves the body by way of the kidneys? 20 40 60 80

80 Explanation: To maintain the potassium balance, the renal system must function, because 80% of the potassium excreted daily leaves the body by way of the kidneys. The other numerical values are incorrect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 268.

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. 9.8 mg/dL 10.3 mg/dL 11 mg/dL 12 mg/dL

9.8 mg/dL Explanation: To calculate corrected serum calcium, subtract the normal serum albumin level of 4 g/dL from the reported albumin level of 3 g/dL, multiply that value (1) by 0.8 (constant factor) and then add that result (0.8 mg) to the reported serum level of 9 mg/dL. Therefore, 9 + 0.8 = 9.8 mg/dL (corrected value). Note: a constant factor of 0.8 is used because, for every decrease in serum albumin of 1 g/dL below 4 g/dL, the total serum calcium level is underestimated by 0.8 mg/dL. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, Chart 13-2: Calculating Corrected Serum Calcium Level, p. 274.

Which of the following measurable urine outputs indicates the client is maintaining adequate fluid intake and balance? A patient with a minimal urine output of 50 mL/hour A patient with a minimal urine output of 10 mL/hour A patient with a minimal urine output of 30 mL/hour A patient with a minimal urine output of 20 mL/hour

A patient with a minimal urine output of 30 mL/hour Explanation: A client with minimal urine output of 30 mL/hour provides the nurse with the information that the patient is maintaining proper fluid balance. Less then 30 mL/hour of urine output indicates dehydration and possible poor kidney function.

The nurse notes that a patient's urine osmolality is 980 mOsm/kg. What should the nurse assess as a possible cause of this finding? Acidosis Fluid volume excess Diabetes insipidus Hyponatremia

Acidosis Explanation: Normal urine osmolality is 200 to 800 mOsm/kg, so 980 mOsm/kg is elevated. Acidosis is a factor that increases urine osmolality. Fluid volume excess, diabetes insipidus, and hyponatremia are all factors that decrease urine osmolality. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Table 13-3 Factors Affecting Serum and Urine Osmolality, p. 255.

A client being treated for a chronic illness has a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which assessment findings will the nurse expect to assess in the client? Select all that apply. Anorexia Hyperactive reflexes Numb fingers Muscle weakness Abdominal distention

Anorexia Muscle weakness Abdominal distention Explanation: A normal serum potassium level ranges from 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Clinical signs and symptoms of a low potassium level include anorexia, muscle weakness, and hypoactive reflexes. Hyperactive reflexes are associated with a low calcium or magnesium level. Numb fingers are associated with a low calcium level.

The nurse is caring for a patient with a diagnosis of hyponatremia. Which nursing intervention is appropriate to include in the plan of care for this patient? Select all that apply. Assessing for symptoms of nausea and malaise Encouraging the intake of low-sodium liquids Monitoring neurologic status Restricting tap water intake Encouraging the use of salt substitute instead of salt

Assessing for symptoms of nausea and malaise Monitoring neurologic status Restricting tap water intake Explanation: For patients at risk of hyponatremia, the nurse closely monitors laboratory values (i.e., sodium) and stays alert for GI manifestations such as anorexia, nausea, vomiting, and abdominal cramping. The nurse must be alert for central nervous system changes, such as lethargy, confusion, muscle twitching, and seizures. Neurologic signs are associated with very low sodium levels that have fallen rapidly because of fluid overloading. For a patient with abnormal loss of sodium who can consume a general diet, the nurse encourages intake of foods and fluids with high sodium content. For example, broth made with one beef cube contains approximately 900 mg of sodium; 8 oz of tomato juice contains approximately 700 mg of sodium. If the primary problem is water retention, it is safer to restrict fluid intake than to administer sodium. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Sodium Deficit (Hyponatremia), p. 266.

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? PaO2 PO2 Carbonic acid Bicarbonate

Bicarbonate Explanation: Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Acid-Base Disturbances, p. 284.

A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply. Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Serum glucose of 90 mg/dL Urine specific gravity of 1.03 Hematocrit level of 48%

Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Urine specific gravity of 1.03 Explanation: Severe dehydration is associated with an increased BUN (N = 10 to 20 mg/dL), serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L) and urine specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would also be elevated but are within normal range for this question. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Laboratory Tests for Evaluating Fluid Status, pp. 255-256.

Interventions for respiratory acidosis?

Bronchodilators for bronchial spasms Antibiotics for resp. infections Thrombolytics or anticoagulants for pulmonary emboli Pulmonary hygiene (clear mucus secretions or purulant drainage) p. 286-287

The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? Red blood cell crenation Red blood cell hydrolysis Cerebral edema Renal failure

Cerebral edema Explanation: Treatment of hypernatremia consists of a gradual lowering of the serum sodium level by the infusion of a hypotonic electrolyte solution (e.g., 0.3% sodium chloride) or an isotonic nonsaline solution (e.g., dextrose 5% in water [D5W]). D5W is indicated when water needs to be replaced without sodium. Clinicians consider a hypotonic sodium solution to be safer than D5W because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. It is the solution of choice in severe hyperglycemia with hypernatremia. A rapid reduction in the serum sodium level temporarily decreases the plasma osmolality below that of the fluid in the brain tissue, causing dangerous cerebral edema. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 268.

A client presents with severe diarrhea and a history of chronic renal failure to the emergency department. Arterial blood gas results are as follows: pH 7.30 PaO2 97 PaCO2 37 HCO3 18 The nurse would expect which of the following sets of assessment findings? Headache, blood pressure 90/54, dry skin Blood pressure 188/120, nausea, vomiting Confusion, respiratory rate 8 breaths/min, dry skin Clammy skin, blood pressure 86/46, headache

Clammy skin, blood pressure 86/46, headache Explanation: Metabolic acidosis, a common clinical disturbance, is characterized by decreased pH and plasma bicarbonate concentration. Common causes of metabolic acidosis include diarrhea, chronic renal failure, use of diuretics, intestinal fistulas, and ureterostomies. The client will experience the following signs and symptoms: headache, confusion, increased respiratory rate, nausea, vomiting, cold and clammy skin, and decreased blood pressure.

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30mmHg; 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? Compensated respiratory alkalosis Uncompensated respiratory alkalosis Compensated metabolic acidosis Compensated metabolic alkalosis

Compensated respiratory alkalosis Explanation: The question states that the client has a history of acid-base disturbance. The nurse would first note that the pH has returned to close to normal indicating compensation. The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3 (normal: 22 to 27mEq/L) levels. In a respiratory condition, the pH and the PCO2 move in opposite direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low, also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Acute and Chronic Respiratory Alkalosis (Carbonic Acid Deficit), p. 287.

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Sunken eyeballs and spasticity Flaccidity and thirst 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 261.

A nurse reviews the results of an electrocardiogram (ECG) for a patient who is being assessed for hypokalemia. Which of the following would the nurse notice as the most significant diagnostic indicator? Widened QRS wave Flat P wave Elevated U wave Peaked T wave

Elevated U wave Explanation: An elevated U wave is specific for hypokalemia. Flat or inverted T waves may also be present. The other tracings are consistent with hyperkalemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, p. 269.

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

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Hypervolemia, p. 262.

Hypokalemia can cause which symptom to occur? Excessive thirst Increased release of insulin Production of concentrated urine Decreased sensitivity to digitalis

Excessive thirst Explanation: If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine and excessive thirst. Potassium depletion depresses the release of insulin and results in glucose intolerance. Decreased sensitivity to digitalis does not occur with hypokalemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 269.

The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply. Extravasation Infection Hematoma Phlebitis Air embolism

Extravasation Infection Hematoma Phlebitis Explanation: Local complications of intravenous therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Infections can be local or systemic. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, and febrile reaction. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 291.

The nurse notes that a client has lost 5 lbs. (2.27 kg) of body weight over 5 days. Which additional assessment findings indicate to the nurse that the client is experiencing hypovolemia? Select all that apply. Lung crackles Flat neck veins Bounding pulse Muscle cramps Concentrated urine

Flat neck veins Muscle cramps Concentrated urine Explanation: An acute weight loss of 5 lbs. (2.27 kg) over 5 days can indicate a fluid volume deficit or hypovolemia. Additional assessment findings that support a loss of fluid include flat neck veins, muscle cramps, and concentrated urine. Lung crackles and a bounding pulse would occur with an excess of fluid or hypervolemia.

Clinical manifestations of hyperMg?

Flushing hypotension muscle weakness drowsiness hypoactive reflexes depressed resp. cardiac arrest coma diaphoresis p. 277

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

Generalized Explanation: There may be generalized edema in all the interstitial spaces, which sometimes is called brawny edema or anasarca. Options B and D are not part of the process of third-spacing fluid. Option C is a distractor for this question.

In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply. Heart failure Pulmonary edema Renal impairment Burns Severe hemorrhage

Heart failure Pulmonary edema Renal impairment Explanation: Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 289.

A physician orders regular insulin 10 units 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? Hypercalcemia Hypernatremia Hyperglycemia Hyperkalemia

Hyperkalemia Explanation: 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. This combination doesn't help reverse the effects of hypercalcemia, hypernatremia, or hyperglycemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Potassium Imbalances, p. 268.

The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition? Dehydration Hypokalemia Hypocalcemia Hypomagnesemia

Hypocalcemia Explanation: Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition, the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, Clinical Manifestations, p. 280.

Clinical manifestation of hyponatremia at 115?

ICP lethargy confusion muscle twitching focal weakness hemiparesis papilledema seizures death p. 265

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? Similar causes are present in both conditions. Hypovolemia contains only low blood volume. In dehydration, only extracellular is depleted. Both conditions result in abnormal laboratory studies.

In dehydration, only extracellular is depleted. Explanation: In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Hypovolemia, p. 259.

The nurse is caring for a client with an arterial blood pH of 7.48 and bicarbonate level of 29 mEq/L (29 mmol/L). Which treatment will the nurse expect to be prescribed for this client? Bronchodilator Potassium supplements Intravenous 0.9% normal saline Oxygen through a rebreather mask

Intravenous 0.9% normal saline Explanation: Treatment of both acute and chronic metabolic alkalosis is aimed at correcting the underlying acid-base disorder. Because volume depletion is commonly present, treatment includes restoring normal fluid volume by administering normal saline. Bronchodilators are used to treat respiratory acidosis. Potassium supplements would be used to treat metabolic acidosis. Oxygen delivered through a rebreather mask would be used to treat respiratory alkalosis.

A client with a magnesium concentration of 2.6 mEq/L (1.3 mmol/L) is being treated on a medical-surgical unit. Which treatment should the nurse anticipate will be used? Intravenous furosemide Fluid restriction Oral magnesium oxide Dialysis

Intravenous furosemide Explanation: The nurse should anticipate the administration of furosemide for the treatment of hypermagnesemia. Administration of loop diuretics (e.g., furosemide) and sodium chloride or lactated Ringer intravenous solution enhances magnesium excretion in clients with adequate renal function. Fluid restriction is contraindicated. The client should be encouraged to increase fluids to promote the excretion magnesium through the urine. Magnesium oxide is contraindicated because it would further elevate the client's serum magnesium concentration. In acute emergencies, when the magnesium concentration is severely elevated, hemodialysis with a magnesium-free dialysate can reduce the serum magnesium to a safe concentration within hours. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 278.

With which condition should the nurse expect that a decrease in serum osmolality will occur? Influenza Hyperglycemia Kidney failure Uremia

Kidney failure Explanation: Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 256.

The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor mostclosely? Magnesium Calcium Phosphorus Potassium

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 277.

The nurse is caring for a client with an acid-base imbalance. For which imbalance will the nurse calculate the anion gap? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis Explanation: The anion gap refers to the difference between the sum of all measured positively charged electrolytes (cations) and the sum of all negatively charged electrolytes (anions) in blood. The anion gap reflects unmeasured anions (phosphates, sulfates, and proteins) in plasma that replace bicarbonate in metabolic acidosis. Measuring the anion gap is necessary when analyzing conditions of metabolic acidosis as it can help determine the cause of the acidosis. Anion gap is calculated primarily to identify the cause of metabolic acidosis.

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? Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis

Metabolic acidosis Explanation: The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) minus (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Acute and Chronic Metabolic Acidosis (Base Bicarbonate Deficit), p. 284.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic acidosis Explanation: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 285.

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? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

Metabolic acidosis Explanation: This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 284.

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? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Metabolic alkalosis Explanation: A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 288.

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? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Metabolic alkalosis Explanation: Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. 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. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Acute and Chronic Metabolic Alkalosis (Base Bicarbonate Excess), p. 285.

The nurse on the telemetry unit is admitting a 49-year-old male client with a potassium level of 6.8 mEq/l (6.8 mmol/l). Monitor for arrhythmias. Administer oral sodium polystyrene sulfonate. Restrict dietary potassium. Infuse NPH insulin intravenously. Monitor vital signs every 8 hours. Assess for muscle weakness.

Monitor for arrhythmias. Restrict dietary potassium. Administer oral sodium polystyrene sulfonate. Hyperkalemia, an elevated serum potassium level greater than 5 mEq/l (5 mmol/l), can cause electrocardiogram (ECG) changes and life-threatening arrhythmias. The client with hyperkalemia should receive continuous cardiac monitoring to detect arrhythmias and ECG changes such as tachycardia, bradycardia, tall tented T waves, prolonged PR interval, and QRS duration, absent P waves, and ST depression. Sodium polystyrene sulfonate, a cation exchange resin, may be administered orally or by retention enema to reduce a high potassium level. This medication binds with potassium and is then eliminated in the feces. An early ECG change, often occurring at a serum potassium level greater than 6 mEq/l (6 mmol/l) is ST-segment depression. Dietary potassium should be restricted to avoid raising the serum potassium level. The nurse should assess the client for signs and symptoms of hyperkalemia, including muscle weakness. Intravenous administration of regular insulin and a hypertonic dextrose solution may be administered to cause a temporary shift of potassium into the cells. NPH inulin is an intermediate-acting insulin that should not be administered intravenously to treat elevated potassium levels. To detect changes in heart rate, blood pressure, and respiratory status, vital signs should be assessed more frequently than every 8 hours. Depending on the condition of the patient, the serum potassium level, and unit policies, vital signs may be assessed as often as every 30 minutes to 1 hour.

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

Monitoring respiratory status for signs and symptoms of pulmonary complications. Explanation: Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 264.

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? Endocrine system Gastrointestinal system Neurological system Musculoskeletal system

Neurological system Explanation: A client with a calcium level of 4.0 mg/dL has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Calcium Deficit (Hypocalcemia), p. 273.

The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a client experiencing hypercalcemia. Which ECG change is typically associated with this electrolyte imbalance? Prolonged PR intervals Prolonged QT intervals Peaked T waves Elevated ST segments

Prolonged PR intervals Explanation: Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium concentration. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 276.

Clinical manifestations of hypocalcemia on EKG?

Prolonged QT Lengthened ST p. 273

The nurse is caring for a client who was admitted with fluid volume excess (FVE). Which nursing assessments should the nurse include in the ongoing monitoring of the client? Select all that apply. Nutritional status and diet Blood pressure, heart rate, and rhythm Intake and output, urine volume, and color Strength testing for muscle wasting Skin assessment for edema and turgor

Nutritional status and diet Blood pressure, heart rate, and rhythm Intake and output, urine volume, and color Skin assessment for edema and turgor Explanation: To assess for FVE the nurse measures blood pressure, heart rate and rhythm, and breath sounds; inspects the skin to look for edema and turgor; and inspects neck veins. Intake and output, daily weight, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess. Treatment of FVE typically involves dietary restriction of sodium. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, , Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Nursing Management, p. 263.

Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply. Offer a diet with fruit juices and citrus fruits. Administer the ordered Kayexalate enema. Administer the ordered furosemide 60 mg po. Monitor intake and output every shift. Administer the ordered potassium 40 mg IV push.

Offer a diet with fruit juices and citrus fruits. Monitor intake and output every shift. Explanation: Hypokalemia is a potassium level less than 3.5 mEq/L. Nurses must have knowledge of this life-threatening imbalance. The nurse would complete appropriate interventions such as offering a diet containing sufficient potassium, which includes fruits and vegetables, and monitoring the intake and output. Approximately 40 mEq of potassium is lost for every liter of urine output. Potassium is never administered via IV push; if IV potassium is needed, it is administered via infusion pump and with careful monitoring (e.g., EEG, BUN/creatinine, urine output) to ensure hyperkalemia does not result. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, Preventing Hypokalemia, p. 270.

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance? Suggest a fluid restriction. Encourage oral fluids. Remove the Hemovac. Offer a prescribed antiemetic medication.

Offer a prescribed antiemetic medication. Explanation: When calculating the intake and output of a client, it is essential to understand that the normal average intake is 2500 mL in adults. Ranges are often noted at 1800 to 3000 mL. Because the client is vomiting, offering a prescribed antiemetic medication would decrease the output from emesis and increase the input as the client may be more accepting of oral fluids. The client should be encouraged more oral intake once vomiting has subsided, but if not possible, intravenous fluids should be increased to avoid dehydration A fluid restriction could cause dehydration. Removing the Hemovac will decrease documented output but may lead to an internal infection from fluid accumulation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Correcting Hypovolemia, p. 262.

A client's potassium level is moderately elevated. The nurse is reviewing the ECG tracing. Identify the area on the tracing where the nurse would expect to see a peak.

Potassium influences cardiac muscle activity. Alterations in potassium levels change myocardial irritability and rhythm. Hyperkalemia is very dangerous; cardiac arrest can occur. Cardiac effects of elevated serum potassium are usually significant when the level is above 8 mEq/L. Hyperkalemia causes skeletal muscle weakness and even paralysis, related to a depolarization block in the muscle. Therefore, ventricular conduction is slowed. The earliest change that can be observed is peaked, narrow T waves on the ECG. If the level continues to rise, eventually the P wave is absent and the QRS complex widens.

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply. Cool area around the insertion site Reddened area along the path of the vein Tender area around the insertion site Ecchymosis at the insertion site Rapid, shallow respirations

Reddened area along the path of the vein Tender area around the insertion site Explanation: Phlebitis is inflammation of a vein and is characterized by a reddened, warm area around an insertion site or along the path of a vein. The involved area is also tender and swollen. The nurse assesses infusion sites and determines the proper action to take. If indications lead to suspected phlebitis, the nurse will discontinue the intravenous line and restart with a different vessel. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Phlebitis, p. 292.

Which of the following is a function of calcitonin? Select all that apply. Reduces bone resorption Increases urinary excretion of calcium Increases deposition of calcium in bones Decreases deposition of phosphorous in bones Decreases urinary excretion of phosphate

Reduces bone resorption Increases urinary excretion of calcium Increases deposition of calcium in bones Explanation: Calcitonin reduces bones resorption, increasing deposition of calcium and phosphorous in the bones, and increases urinary excretion of calcium and phosphate. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Pharmacologic Therapy, p. 276.

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? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory alkalosis Explanation: A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 287.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? Restricting fluids to 800 ml/day Administering vasopressin as ordered Elevating the head of the client's bed to 90 degrees Restricting sodium intake to 1 gm/day

Restricting fluids to 800 ml/day Explanation: Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 266.

Which of the following may be the first sign of respiratory acidosis in anesthetized patients? Ventricular fibrillation Increased pulse Mental cloudiness Dull headache

Ventricular fibrillation Explanation: Ventricular fibrillation may be the first sign of respiratory acidosis in anesthetized patients. Clinical signs in acute and chronic respiratory acidosis include sudden hypercapnia that can cause increased pulse and respiratory rate, mental cloudiness, dull headache or weakness.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum sodium level of 124 mEq/L Serum creatinine level of 0.4 mg/dl Hematocrit of 52% Serum blood urea nitrogen (BUN) level of 8.6 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 266.

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? Sodium level of 137 mEq/L Potassium level of 3.8 mEq/L Sodium level of 150 mEq/L Potassium level of 6 mEq/L

Sodium level of 150 mEq/L Explanation: Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 265.

Which of the following is a factor affecting an increase in urine osmolality? Syndrome of inappropriate antidiuretic hormone release (SIADH) Alkalosis Fluid volume excess Myocardial infarction

Syndrome of inappropriate antidiuretic hormone release (SIADH) Explanation: Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and congestive heart failure. Myocardial infarction typically is not a factor that increases urine osmolality. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 264.

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

Tachypnea Weakness Lethargy Explanation: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride concentration is accompanied by a high sodium concentration and fluid retention. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 282.

Interventions for resp. alkalosis?

Treat underlying cause. Such as hyperventilating from anxiety then breathe in paper bag to get CO2 back in. May need antianxiety med.

A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess: Trousseau's sign. Homans' sign. Hegar's sign. Goodell's sign.

Trousseau's sign. Explanation: This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans' sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar's sign (softening of the uterine isthmus) and Goodell's sign (cervical softening) are probable signs of pregnancy. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 273.

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

Urine pH of 3.0 Explanation: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 256.

A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of: a. Increased serum HCO3. b. Increased PaCO2. c. Decreased serum HCO3. d. Decreased PaCO2.

b. Increased PaCO2. Explanation: The respiratory system compensates by decreasing ventilation to conserve CO2 and increase the PaCO2. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluids and Electrolytes: Balance and Disturbance, p. 285.

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 overhydration hyponatremia

free water loss Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Table 13-3 Factors Affecting Serum and Urine Osmolality, p. 255.

A client with mild fluid volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this client? bumetanide torsemide hydrochlorothiazide furosemide

hydrochlorothiazide Explanation: Generally, thiazide diuretics, such as hydrochlorothiazide (HydroDIURIL) or chlorthalidone (Thalitone), are prescribed for mild to moderate hypervolemia and loop diuretics for severe hypervolemia. Thiazide diuretics block sodium reabsorption in the distal tubule, where only 5% to 10% of filtered sodium is reabsorbed. Loop diuretics, such as furosemide (Lasix), bumetanide (Bumex), or torsemide (Demadex), can cause a greater loss of both sodium and water because they block sodium reabsorption in the ascending limb of Henle's loop, where 20% to 30% of filtered sodium is normally reabsorbed. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Hypervolemia, p. 262.

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: hypernatremia. hypokalemia. hyperkalemia. hypercalcemia.

hyperkalemia. Explanation: Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. Administering glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 272.

A client is experiencing edema in the tissue. What type of intravenous fluid would the nurse expect to be prescribed? isotonic fluid no intravenous solution hypertonic solution hypotonic solution

hypertonic solution Explanation: A hypertonic solution is used to pull water back in to circulation, as it has more particles than the body's water. If hypertonics are given too rapidly or in large quantities, they may cause an extracellular volume excess and precipitate circulatory overload and dehydration. As a result, these solutions must be given cautiously and usually only when the serum osmolality has decreased to dangerously low levels. Hypertonic solutions exert an osmotic pressure greater than that of the extracellular fluid. The hospitalized client requires treatment for the tissue edema. An isotonic solution is the same concentration as the body's water and is used as an intravenous volume expander. A hypotonic solution has fewer particles than the body's water, thus shifting water from the vascular space to the tissue. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Table 13-5: Selected Water and Electrolyte Solutions, p. 261.

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

hypokalemia Explanation: Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 268.

A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia? hypervolemia hypercalcemia hypomagnesemia hypermagnesemia

hypomagnesemia Explanation: If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Clinical Manifestations, p. 278.

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 hypocalcemia hypomagnesemia

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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Magnesium Deficit (Hypomagnesemia), p. 277.

Which set of arterial blood gas (ABG) results requires further investigation? 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 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L pH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, and HCO3- 26 mEq/L 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 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 287.

The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L pH: 7.40, PaCO2: 40 mm Hg, HCO3-: 24 mEq /L

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35-7.40 and the PaCO2 is greater than 40-45 mm Hg and a compensatory increase in the plasma HCO3- occurs. Respiratory acidosis may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.40, PaCO2: 40 mm Hg, and HCO3-: 24 mEq/L indicate a normal result/no imbalance. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, Chart 13-3, pp. 286-287.

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

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis, where only gastric fluid is lost. The other results do not represent metabolic alkalosis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 285.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. What client complication associated with respiratory acidosis would the nurse observe? papilledema stroke seizures hyperglycemia

papilledema Explanation: If respiratory acidosis is severe, intracranial pressure may rise, causing papilledema. Stroke and hyperglycemia are not associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 286.

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? third-spacing pitting edema anasarca hypovolemia

third-spacing Explanation: Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites. Pitting edema occurs when indentations remain in the skin after compression. Anasarca is another term for generalized edema, or brawny edema, in which the interstitial spaces fill with fluid. Hypovolemia (fluid volume deficit) refers to a low volume of extracellular fluid. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 259.