Ch13: Fluid and Electrolytes: Balance and Disturbance - ML8
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 can use laxatives and enemas but only once a week." "A good breakfast for me will include milk and a couple of bananas." "I will be sure to buy frozen vegetables when I grocery shop." "I will take a potassium supplement daily as prescribed."
"I can use laxatives and enemas but only once a week." The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives, diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, client education may help alleviate the problem.
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 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.
Which solution is hypotonic? Lactated Ringer solution 0.45% NaCl 0.9% NaCl 5% NaCl
0.45% NaCl Half-strength saline is hypotonic. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A 5% NaCl solution is hypertonic.
The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer? 0.45% sodium chloride 0.9% sodium chloride 5% glucose in water 5% glucose in normal saline solution
0.45% sodium chloride Half-strength saline (0.45% sodium chloride) solution is frequently used as an IV hypotonic solution.
A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? <136 mOsm/kg 275-300 mOsm/kg >408 mOsm/kg 350-544 mOsm/kg
275-300 mOsm/kg In healthy adults, normal serum osmolality is 270 to 300 mOsm/kg (Crawford & Harris, 2011c).
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 7.45 7.35 7.30
7.50 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.
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 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.
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 7-year-old with a fracture tibia A 65-year-old with a myocardial infarction A 52-year-old with diarrhea A 72-year-old with a total knee repair
A 52-year-old with diarrhea 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.
Hypomagnesemia is a common yet often overlooked imbalance in acutely and critically ill patients. Which of the following patients is most likely at the highest risk of experiencing low serum magnesium levels? An obese male patient who has a history of atherosclerosis and a previous non-ST wave elevation myocardial infarction A patient who is temporarily receiving total parenteral nutrition (TPN) as a result of complications from gastric bypass surgery A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use A teenage patient who is currently being treated for non-Hodgkin's lymphoma (NHL)
A female patient who has liver cirrhosis and who is experiencing withdrawal from heavy alcohol use Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Hypomagnesemia is particularly troublesome during treatment of alcohol withdrawal. Therefore, the serum magnesium level should be routinely measured in patients undergoing withdrawal from alcohol. TPN, heart disease, and lymphoma are not identified as central risk factors for the development of hypomagnesemia.
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? Chest pain Hypertension Slow pulse Jaundice
Chest pain Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.
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. Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Administer IV bicarbonate. Suction the client's airway.
Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. 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.
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 Headache Nausea Hallucinations
Confusion Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <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. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.
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 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.
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? Myasthenia gravis Type 1 diabetes mellitus Extreme anxiety Opioid overdose
Extreme anxiety 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's 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.
A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patient's most recent blood work indicates a K+ level of 2.7 mEq/L. This potassium level should prompt the nurse to assess for which of the following physical manifestations? Confusion and decreased level of consciousness Shortness of breath, rales, and peripheral edema Dysphagia, tetany, and emotional lability Fatigue, cramps, and weakness
Fatigue, cramps, and weakness A serum potassium level of 2.7 mEq/L constitutes hypokalemia. Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), arrhythmias, and increased sensitivity to digitalis. Respiratory symptoms, dysphagia, and tetany are not typically associated with hypokalemia.
The nurse is caring for a client who is exhibiting symptoms of tachypnea and circumoral paresthesias. What should be the nurse's first course of action? Stop mechanical ventilation. Administer cardiopulmonary resuscitation (CPR). Give a dose of aspirin. Find and correct the cause of tachypnea.
Find and correct the cause of tachypnea. Tachypnea or rapid breathing may result from various reasons including acute anxiety, high fever, thyrotoxicosis, early salicylate poisoning, hypoxemia, or mechanical ventilation. The rapid breathing expels more CO2 than necessary. This causes a deficit in carbonic acid, leading to respiratory alkalosis. Circumoral paresthesia is one of the symptoms. The first course of action is to detect and treat the cause of tachypnea. The nurse has to maintain mechanical ventilation if the client is dependent on it. CPR administration is required only if the client's condition needs it. Aspirin is not advised as early aspirin poisoning may be a cause of the tachypnea.
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? Hyperkalemia Hypocalcemia Hypokalemia Hypercalcemia
Hypercalcemia The normal reference range for serum calcium is 8.6 to 10.2 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? Administer an ordered decongestant. Instruct the client to breathe into a paper bag. Offer the client fluids frequently. Administer ordered supplemental oxygen.
Instruct the client to breathe into a paper bag. The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
Metabolic acidosis Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg.
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 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.
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 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.
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
Metabolic alkalosis Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma biacarbonate concentration. The most common cuase of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.
Which is a correct route of administration for potassium? Subcutaneous Intramuscular Oral IV (intravenous) push
Oral Potassium may be administered through the oral route. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. Potassium is not administered subcutaneously.
The calcium concentration in the blood is regulated by which mechanism? Parathyroid hormone (PTH) Thyroid hormone (TH) Adrenal gland Androgens
Parathyroid hormone (PTH) The serum calcium concentration is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium concentration in the blood.
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? CO2 Sodium Chloride Potassium
Potassium The nurse should identify potassium: 2.2 mEq/L as critical because a normal potassium level is 3.5 to 5.0 mEq/L. Severe hypokalemia can cause cardiac and respiratory arrest, possibly leading to death. Hypokalemia also depresses the release of insulin and results in glucose intolerance. The glucose level is above normal (normal is 75 to 110 mg/dl) and the chloride level is a bit low (normal is 100 to 110 mEq/L). Although these levels should be reported, neither is life-threatening. The BUN (normal is 8 to 26 mg/dl) and creatinine (normal is 0.8 to 1.4 mg/dl) are within normal range.
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Monitor the client's heart rhythm. Prepare for gastric lavage. Obtain a urine specimen for drug screening.
Prepare to assist with ventilation. Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? Presence of Trousseau sign Slurred speech Negative Chvostek sign Muscle weakness
Presence of Trousseau sign After radical neck resection, a client is prone to developing hypocalcemia. Hypocalcemia is defined as a serum value <8.6 mg/dL (<2.15 mmol/L). Signs and symptoms of hypocalcemia include Chvostek sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped; and a positive Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.
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 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.
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? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis
Respiratory acidosis The pH <7.40, PaCO2 >40, and the HCO3 is normal, therefore it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. Option B is incorrect, the HCO3 = 24, which is within the normal range so it is not metabolic alkalosis. Option C is incorrect, the pH = 7.21, so it is an acidosis not alkalosis. Option D is incorrect, the pH = 7.21 so it is an acidosis, but the HCO3 = 24, which is within the normal range so it is not a metabolic acidosis.
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 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.
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 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.
The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action? Send the client for a chest x-ray. Administer the prescribed IV fluids. Obtain written consent for the procedure. Assess the client's blood pressure (BP) on the right arm.
Send the client for a chest x-ray. A chest x-ray is needed to confirm the placement of catheter tip before initiating ordered infusions. Consent should be obtained before, not after, the procedure. No BPs should be taken on the extremity where the catheter is placed.
Which of the following arterial blood gas results would be consistent with metabolic alkalosis? Serum bicarbonate of 28 mEq/L PaCO2 less than 35 mm Hg Serum bicarbonate of 21 mEq/L pH 7.26
Serum bicarbonate of 28 mEq/L Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
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 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 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 Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? Bradycardia Tachycardia Vasodilation Increased urine output
Tachycardia Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.
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 his physician 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 care insurance office.
The client had a liver transplant 2 years ago. 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.
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)? 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 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 Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.
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 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.
A client is brought in by ambulance in a nauseous and confused state and demonstrating carpopedal spasm. Initial arterial blood gases show increased pH and HCO3 and normal PaCO2 levels. Breathing is slow and shallow. As the nurse caring for this client, you know that potassium salt should be a part of the treatment for this client when? Always When hypokalemia is present When there is volume depletion When base bicarbonate accumulates
When hypokalemia is present The findings suggest metabolic alkalosis. Treatment involves eliminating the cause. Loss of hydrogen and chloride ions may be one of the causes, and this loss can be a result of hypokalemia. Potassium salt should be administered if there is evidence of hypokalemia. It is not always part of the treatment for metabolic alkalosis. If there is volume depletion, the nurse should always administer sodium chloride solutions. Accumulation of base bicarbonate is what leads to metabolic alkalosis and is not a defining condition for treatment with potassium.
A client is brought in by ambulance in a nauseous and confused state and demonstrating carpopedal spasm. Initial arterial blood gases show increased pH and HCO3 and normal PaCO2 levels. Breathing is slow and shallow. As the nurse caring for this client, you know that potassium salt should be a part of the treatment for this client when? Always When hypokalemia is present When there is volume depletion When base bicarbonate accumulates
When hypokalemia is present The findings suggest metabolic alkalosis. Treatment involves eliminating the cause. Loss of hydrogen and chloride ions may be one of the causes, and this loss can be a result of hypokalemia. Potassium salt should be administered if there is evidence of hypokalemia. It is not always part of the treatment for metabolic alkalosis. If there is volume depletion, the nurse should always administer sodium chloride solutions. Accumulation of base bicarbonate is what leads to metabolic alkalosis and is not a defining condition for treatment with potassium.
A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the malignancy is causing the electrolyte imbalance. client's diet is lacking in calcium-rich food products. client may be developing hyperaldosteronism. client has a history of alcohol abuse.
malignancy is causing the electrolyte imbalance. The client's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium concentration >10.2 mg/dL (>2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia through a variety of mechanisms. The client's calcium level is elevated; there is no indication that the client's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.
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: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It 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 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.
A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. The laboratory values are as follows:sodium 142 mEq/L (142 mmol/L)potassium 3.0 mEq/L (3.0 mmol/L)chloride 106 mEq/L (106 mmol/L)Magnesium 2.3 mg/dL (0.95 mmol/L) What laboratory value is consistent with the client's symptoms? sodium 147 mEq/L (147 mmol/L) potassium 3.0 mEq/L (3.0 mmol/L) chloride 112 mEq/L (112 mmol/L) magnesium 2.3 mg/dL (0.95 mmol/L)
potassium 3.0 mEq/L (3.0 mmol/L) Potassium is the major intracellular electrolyte. Hypokalemia (potassium levels lower than 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias. The sodium, chloride, and magnesium levels listed are within normal limits.
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 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. Anascara 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.
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 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'll drink cranberry juice with my breakfast instead of coffee." "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." 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.
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 A 2-lb weight gain in 24 hours indicates that the client is retaining 1L of fluid.
Below which serum sodium concentration might convulsions or coma occur? 135 mEq/L (135 mmol/L) 145 mEq/L (145 mmol/L) 140 mEq/L (140 mmol/L) 142 mEq/L (142 mmol/L)
135 mEq/L (135 mmol/L) 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.
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. 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.
What percentage of potassium excreted daily leaves the body by way of the kidneys? 20 40 60 80
80 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.
As part of a large hospital's IV team, two nurses are responsible for inserting peripherally inserted central catheters (PICCs) at the bedside for patients who require this form of venous access. Which of the following patients would most likely require a PICC? A woman who recently suffered a pelvic fracture in a motor vehicle accident An elderly man who has been admitted from the community with a fluid volume deficit A man whose hypocalcemia requires a stat infusion of calcium gluconate A woman who has just been ordered total parenteral nutrition (TPN)
A woman who has just been ordered total parenteral nutrition (TPN) Parenteral nutrition is a common indication for the use of a PICC. The other patients' needs are more likely to be met with a peripheral IV, although a PICC is not contraindicated.
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution? Neutral Alkaline Acidic Basic
Acidic Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
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 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.
The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)? Osmosis Passive diffusion Facilitated diffusion Active transport
Active transport Active transport requires the use of the body's energy molecule (ATP) to meet body needs for fluid and particle transport. Osmosis is the movement of body fluids through a semipermeable membrane that allows not all substances to pass through. Passive diffusion allows the movement of substances from an area of higher concentration to lower concentration. Facilitated diffusion has certain dissolved substances that require the assistance from a carrier module to pass through the semipermeable membrane.
Which is the most common cause of symptomatic hypomagnesemia? Intravenous drug use Alcoholism Sedentary lifestyle Burns
Alcoholism Alcoholism is currently the most common cause of symptomatic hypomagnesemia. Intravenous drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia.
The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet. A 79-year-old client admitted with a diagnosis of pneumonia. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift.
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.
The nurse is caring for a patient with a metabolic acidosis (pH 7.25). Which of the following values is useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss? Anion gap PaCO2 Bicarbonate level Serum sodium level
Anion gap Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.
The nurse is caring for a patient with a diagnosis of hyponatremia. What 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 For patients at risk, the nurse closely laboratory values (i.e., sodium) and be 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 losses of sodium who can consume a general diet, the nurse encourages foods and fluids with high sodium content to control hyponatremia. 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.
A volume-depleted patient would present with which of the following diagnostic lab results? BUN-to-creatinine ratio of 24:1 Urinary output of 1.2 L/24 hours Urine specific gravity of 1.02 Capillary refill time of 3 seconds
BUN-to-creatinine ratio of 24:1 A BUN-to-serum creatinine concentration ratio greater than 20:1 is indicative of volume depletion. The other results are within normal range.
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 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.
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 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.
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
Blood pressure, heart rate, and rhythm Intake and output, urine volume, and color Skin assessment for edema and turgor 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.
A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned? Potassium Phosphorus Calcium Magnesium
Calcium 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.
Which electrolyte is a major anion in body fluid? Chloride Potassium Sodium Calcium
Chloride Chloride is a major anion found in extracellular fluid. Potassium, sodium, and calcium are cations.
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 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 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).
You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? Hypovolemia Dehydration Hypervolemia Fluid volume excess
Dehydration The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances. Therefore, options A, C, and D are incorrect.
You are caring for a client with severe hypokalemia. The physician has ordered IV potassium to be administered at 10 mEq/hr. The client complains of burning along their vein. What should you do? Dilute the infusion. Switch to an oral formulation. Increase the speed of transfusion. Change the electrolyte.
Dilute the infusion. Treatment of severe hypokalemia requires treatment with IV infusion of potassium. Clients may experience burning along the vein with IV infusion of potassium in proportion to the infusion's concentration. If the client can tolerate the fluid, consult with the physician about diluting the potassium in a larger volume of IV solution. Oral potassium may not be enough in severe cases hypokalemia. Hypokalemia requires treatment with potassium and not any other electrolyte.
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Distended neck veins Crackles in the lung fields Shortness of breath Decreased blood pressure Bradycardia
Distended neck veins Crackles in the lung fields Shortness of breath Clinical manifestations of FVE include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.
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 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.
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 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.
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Abnormal potassium level Elevated hematocrit level Low white blood count Low urine specific gravity
Elevated hematocrit level When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.
Hypokalemia can cause which symptom to occur? Excessive thirst Increased release of insulin Production of concentrated urine Decreased sensitivity to digitalis
Excessive thirst 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.
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Extracellular fluid volume deficit Altered blood urea nitrogen (BUN) value Metabolic alkalosis Respiratory acidosis
Extracellular fluid volume deficit Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. A cause of this loss is hemorrhage.
What foods can the nurse recommend for the patient with hypokalemia? Fruits such as bananas and apricots Green, leafy vegetables Milk and yogurt Nuts and legumes
Fruits such as bananas and apricots Sources of potassium include fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains (Crawford & Harris, 2011b).
A patient has a serum osmolality of 250 mOsm/kg. The nurse knows to assess further for: Dehydration. Hyperglycemia. Hyponatremia. Acidosis.
Hyponatremia. Decreased serum sodium is a factor associated with decreased serum osmolality. Dehydration and hyperglycemia are associated with increased serum osmolality; acidosis is associated with increased urine osmolality.
Oral intake is controlled by the thirst center, located in which of the following cerebral areas? Hypothalamus Cerebellum Brainstem Thalamus
Hypothalamus Oral intake is controlled by the thirst center located in the hypothalamus. The thirst center is not located in the cerebellum, brainstem, or thalamus.
Which could be a potential cause of respiratory acidosis? Vomiting Hypoventilation Diarrhea Hyperventilation
Hypoventilation Respiratory acidosis is always due to inadequate excretion of CO2, with inadequate ventilation, resulting in elevated plasma CO concentration, which causes increased levels of carbonic acid. In addition to an elevated PaCO2, hypoventilation usually causes a decrease in PaO2.
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? No effect Increases arterial pH Decreases arterial pH Provides long-term pH regulation
Increases arterial pH 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 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 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.
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 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.
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? Tetanic contractions Jugular vein distention Weight loss Polyuria
Jugular vein distention Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.
Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? Tetanic contractions Jugular vein distention Weight loss Polyuria
Jugular vein distention SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).
A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client? Slow heart rate Kidney stones and blood clots Imbalance in electrolytes Elevated central venous pressure (CVP)
Kidney stones and blood clots Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high as the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below 4 cm H2O.
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? 5% dextrose and normal saline solution Lactated Ringer's solution Half-normal saline solution 10% dextrose in water
Lactated Ringer's solution Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Nausea or vomiting Abdominal pain or diarrhea Hallucinations or tinnitus Light-headedness or paresthesia
Light-headedness or paresthesia The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? Give medications that promote fluid retention. Limit sodium and water intake. Assess for dehydration. Teach client behaviors that decrease urination.
Limit sodium and water intake. Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate interventions.
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? Kidney and liver Heart and lungs Lungs and kidney Pancreas and stomach
Lungs and kidney The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.
The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor mostclosely? Magnesium Calcium Phosphorus Potassium
Magnesium 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? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis
Metabolic alkalosis 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.
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? Yes, this will correct the sodium deficit. Yes, along with the hypotonic IV. No, start with the sodium chloride IV. No, sodium intake should be restricted.
No, sodium intake should be restricted. The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.
A patient with abnormal sodium losses is receiving a regular diet. How can the nurse supplement the patient's diet to provide 1,600 mg of sodium daily? One beef cube and 8 oz of tomato juice Four beef cubes and 8 oz of tomato juice One beef cube and 16 oz of tomato juice One beef cube and 12 oz of tomato juice
One beef cube and 8 oz of tomato juice For a patient with abnormal losses of sodium who can consume a general diet, the nurse encourages foods and fluids with high sodium content to control hyponatremia. 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. The nurse also needs to be familiar with the sodium content of parenteral fluids (see Table 13-5).
A nurse in the Medical ICU has orders to infuse a hypertonic solution into a patient with low blood pressure. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. What term or terms are associated with this process? Hydrostatic pressure Osmosis and osmolality Diffusion Active transport
Osmosis and osmolality Osmosis is the movement of fluid from a region of low solute concentration to the region of high solute concentration across a semipermeable membrane. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. Giving a patient who has low blood pressure a hypertonic solution will increase the number of dissolved particles in the blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move, so diffusion should not be normally taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.
Which electrolyte is a major cation in body fluid? Chloride Bicarbonate Potassium Phosphate
Potassium Potassium is a major cation that affects cardiac muscle functioning. Chloride, bicarbonate, and phosphate are anions.
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? Provide oral care every 2-3 hours. Monitor for signs and symptoms of dehydration. Teach the client about increased fluid intake. Assess the client's weight daily for trends.
Provide oral care every 2-3 hours. 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? Blood pressure Respirations Temperature Pulse
Pulse An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client's pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing respirations and temperature because these aren't affected by the serum potassium level.
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis
Respiratory alkalosis Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.
A patient with a history of poorly controlled type 1 diabetes has begun displaying the characteristic signs and symptoms of diabetic nephropathy. The patient's nurse recognizes that the patient is at risk of disruptions to fluid balance. What role do the kidneys play in the maintenance of normal fluid balance? Secreting or withholding antidiuretic hormone in response to extracellular fluid volume Selectively retaining needed substances and excreting waste products Synthesizing and releasing angiotensin in cases of fluid volume deficit Maintaining the correct concentration of H+ ions in the blood
Selectively retaining needed substances and excreting waste products Major functions of the kidneys in maintaining normal fluid balance include regulation of extracellular fluid (ECF) volume and osmolality by selective retention and excretion of body fluids and regulation of electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded substances. Antidiuretic hormone (ADH) is secreted by the pituitary gland, and angiotensin is ultimately derived from the liver, not the kidneys. Concentration of H+ ions contributes the buffer action of the kidneys, not the maintenance of fluid balance.
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) 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.
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH? The lungs are unable to breathe in sufficient oxygen. The lungs are unable to exchange oxygen and carbon dioxide. The lungs have ineffective cilia from years of smoking. The lungs are not able to blow off carbon dioxide.
The lungs are not able to blow off carbon dioxide. In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, it is the lungs ability to remove the carbon dioxide from the system. Although individuals with COPD frequently have a history of smoking, cilia is not the cause of the acidosis.
A client with emphysema is at a greater risk for developing which acid-base imbalance? chronic respiratory acidosis metabolic alkalosis metabolic acidosis respiratory alkalosis
chronic respiratory acidosis 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.
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. 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.
A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin) for hypotension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance? hypokalemia hyperkalemia hypocalcemia hypercalcemia
hypokalemia 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.
Early signs of hypervolemia include a decrease in blood pressure. thirst. moist breath sounds. increased breathing effort and weight gain.
increased breathing effort and weight gain. 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 alkalosis metabolic acidosis respiratory acidosis respiratory alkalosis
metabolic alkalosis 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.
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by: muscle weakness. tremors. diaphoresis. constipation.
muscle weakness. Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.
Oncotic pressure refers to the number of dissolved particles contained in a unit of fluid. excretion of substances such as glucose through increased urine output. amount of pressure needed to stop the flow of water by osmosis. osmotic pressure exerted by proteins.
osmotic pressure exerted by proteins. Oncotic pressure is a pulling pressure exerted by proteins such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when urine output increases as a result o fexcretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.
The nursing student asks their instructor what the term is for the amount of hydrogen ions in a solution. What should the instructor respond? pH ATP DTATP H+
pH The symbol pH refers to the amount of hydrogen ions in a solution; pH can range from 1, which is highly acidic, to 14, which is highly basic. All other options are incorrect.
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. pH PaCO2 HCO3 Glucose Na+ K+
pH PaCO2 HCO3 Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate (HCO3). The two types of acid-base imbalances are acidosis and alkalosis.
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? HCO 21 mEq/L pH 7.48 PaCO 36 O saturation 95%
pH 7.48 Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.
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. 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.
