CH3 Patho Adapative Quiz
A patient has metabolic acidosis and breathes deeply and rapidly. How does the nurse report this finding to the oncoming shift? "Hypoventilation is present." "Hypochloremia is present." "Isotonic respirations are present." "Kussmaul respirations are present."
"Kussmaul respirations are present." Rationale The respiratory system's efforts to compensate for the increase in metabolic acids in metabolic acidosis result in what are termed Kussmaul respirations (a form of hyperventilation), which are deep and rapid. Hypochloremia, a low level of serum chloride, usually occurs with hyponatremia or an elevated bicarbonate concentration, as in metabolic alkalosis; it is not a type of breathing pattern. The term isotonic indicates that a solution has the same concentration as normal saline; it does not describe a breathing pattern. Breathing rapidly is hyperventilation, not hypoventilation.
When planning care for a normal adult male patient, what percentage of body weight is total body water? 40% 60% 80% 100%
60% Rationale Total body water is about 60% of body weight in a normal adult male patient; 40% is too low, and 80% and 100% are too high.
While the nurse reviews arterial blood gas results, which finding indicates the adult patient has a normal arterial blood pH? 2.0 5.5 7.4 8.0
7.4 An acceptable range for arterial blood pH is 7.35 to 7.45; thus, 7.4 is normal. Gastric juices have a pH of 1.0 to 3.0. Urine pH is 5.0 to 6.0. Pancreatic fluid pH is 7.8 to 8.0.
Which clinical condition causes the nurse to closely monitor a patient for hypernatremia? Compulsive water drinking Excessive dietary potassium Decreased aldosterone secretion Decreased antidiuretic hormone secretion
Decreased antidiuretic hormone secretion Rationale Decreased antidiuretic hormone secretion is a cause of diabetes insipidus, which prevents water reabsorption in the kidneys, creating large volumes of dilute urine and leading to hypernatremia. Compulsive water drinking leads to water intoxication and hyponatremia. Excessive dietary potassium would not affect the serum sodium concentration. Oversecretion of aldosterone, not a decrease in aldosterone secretion, causes hypernatremia.
A co-worker asked the nurse where one third of a patient's total body water is located. How does the nurse respond? In the lymphatic compartment In the intracellular compartment In the extracellular compartment In the intravascular compartment
In the extracellular compartment Rationale Extracellular fluid (ECF) is all the fluid outside the cells (about one third of total body water) and is divided into smaller compartments. The two main ECF compartments are the interstitial fluid (the space between cells and outside the blood vessels) and the intravascular fluid (blood plasma). Lymph is a small ECF compartment. Two thirds of the body's water is intracellular.
A patient asked their nurse, "What regulates potassium levels because I take a fluid pill every day?" How does the nurse respond? The lungs The glands The kidneys The stomach
The kidneys Rationale Although potassium is found in most body fluids, the kidney is the most efficient regulator of potassium balance. The lungs regulate carbon dioxide. The glands regulate hormones. The stomach regulates acid release for digestion.
A nurse cares for patients with edema. Which patient conditions lead to edema formation? Select all that apply. Isotonic fluid loss Venous obstruction Increased salt and water retention Decreased circulatory blood volume Decreased serum albumin production
Venous obstruction Increased salt and water retention Decreased serum albumin production Rationale Venous obstruction causes hydrostatic pressure to increase behind the obstruction, pushing fluid from the capillaries into the interstitial spaces (causing edema). Increased salt and water retention causes plasma volume overload, increased capillary hydrostatic pressure, and edema. Albumin is the primary plasma protein responsible for capillary oncotic pressure. Decreased albumin levels will lower capillary oncotic pressure and decrease reabsorption of fluid from the interstitial space into the vascular space, leading to edema. Isotonic fluid loss and decreased circulatory blood volume will decrease capillary hydrostatic pressure. Edema formation will not occur in these situations.
Which assessment findings does the nurse expect to find in a patient with isotonic fluid loss? Select all that apply. Dry skin Weight loss Distended neck veins Decreased urine output Moist mucous membranes
dry skin weight loss decreased UO Rationale There is loss of extracellular fluid volume with isotonic fluid loss, causing weight loss, dryness of skin and mucous membranes, decreased urine output, and symptoms of hypovolemia. Distended neck veins occur in isotonic fluid excess. Moist mucous membranes are normal.
A nurse assesses an infant experiencing dehydration. Which assessment findings support this condition? Select all that apply. Irritability Sunken fontanels Decreased heart rate Decreased urine output Decreased skin elasticity
irritability sunken fontanels decreased UO decreased skin elasticity Rationale Symptoms of dehydration in infants include increased thirst, decreased urine output, decreased body weight, decreased skin elasticity, sunken fontanels, absent tears, dry mucous membranes, increased (not decreased) heart rate, and irritability.
A patient is having problems with bicarbonate reabsorption and regeneration. Which acid/base organ does the nurse assess? Heart Lungs Kidneys Ionic shifts
kidneys Rationale Kidneys are the organs that regulate bicarbonate reabsorption and regeneration. The lungs regulate retention or elimination of CO 2. The heart is not associated with acid/base balance. Ionic shifts exchange intracellular potassium and sodium for hydrogen.
Fill in the blank Which serum sodium level result indicates to the nurse that a patient has hyponatremia? Record the answer as a whole number. Below
135 Rationale Hyponatremia occurs when the serum sodium drops below 135 mEq/L.
Which condition is the patient experiencing when the arterial blood pH is high? An acidic condition An alkaline condition A metabolic condition A respiratory condition
An alkaline condition Rationale The lower the [H +], the more alkaline or basic the solution and the higher the pH. A low pH is acidic. Although the acid-base imbalance may be caused by either metabolic or respiratory pathosis, the scenario given here does not include any clues as to which of those is occurring; the only fact that is known is that the condition is alkaline.
Which assessment findings does the nurse expect to be present in the patient with hyponatremia? Select all that apply. Confusion Hyperreflexia Muscle weakness Serum sodium level, 130 mEq/L Serum chloride level, 112 mEq/L
Confusion Muscle weakness Serum sodium level, 130 mEq/L Rationale Hyponatremia occurs when the serum sodium level drops below 135 mEq/L. Confusion and muscle weakness occur because of changes in the action potential of neurons and muscles. Depressed reflexes occur in hyponatremia. Hyperreflexia is a manifestation of hypernatremia. Hypochloremia (chloride level less than 97 mEq/L) occurs with hyponatremia. Hyperchloremia (chloride level greater than 105 mEq/L) occurs with hypernatremia.
Which change in laboratory values does the nurse assess as evidence of renal compensation for a patient's respiratory acidosis? Elevated carbon dioxide Decreased carbon dioxide Elevated bicarbonate ion concentration Decreased bicarbonate ion concentration
Elevated bicarbonate ion concentration Rationale Renal compensation or respiratory acidosis occurs by elimination of hydrogen ions and retention of bicarbonate. Elevated carbon dioxide is evidence of respiratory acidosis, not of compensation for it. The lungs manage the carbon dioxide concentration. Decreased bicarbonate ion concentration would make the acidosis worse.
Which substance in a patient's body is the most acidic? Urine Venous blood Gastric juices Pancreatic fluid
Gastric juices Rationale Gastric juices have pH 1.0 to 3.0, which is the most acidic in this group. Venous blood has pH 7.37, which is mildly basic. Urine usually has pH 5.0 to 6.0, which is mildly acidic. Pancreatic fluid has pH 7.8 to 8.0, which is mildly basic.
A nurse discusses alterations in calcium, phosphate, and magnesium. What is the nurse discussing? Imbalances in a patient's acid levels Imbalances in a patient's anion levels Imbalances in a patient's glucose levels Imbalances in a patient's electrolyte levels
Imbalances in a patient's electrolyte levels Rationale Calcium, phosphate, and magnesium are all cations (positively charged) and electrolytes. The acid level is the amount of hydrogen in the body, which is indicated by carbonic acid levels. The anions are the negatively charged particles in the body. Glucose is a nonelectrolyte.
When a patient begins to develop metabolic acidosis, the nurse expects to assess which breathing pattern? Increased rate and shallow depth Decreased rate and shallow depth Increased rate and increased depth Decreased rate and increased depth
Increased rate and increased depth Rationale The respiratory system adjusts the amount of carbonic acid that remains in the body when there is an excess of metabolic acids; therefore the rate and depth of respirations will increase (resulting in Kussmaul respirations) so that excess carbonic acid is removed. If too little carbonic acid is present in the blood, the rate and depth of the respirations will decrease to retain carbonic acid until it is once more present in normal amounts.
A patient has ascites. Which area does the nurse assess? Feet Heart Pleural space Peritoneal space
Peritoneal space Rationale Ascites is accumulation of fluid in the peritoneal space. Pleural effusion is fluid accumulation in the pleural space. Fluid accumulation in the feet is localized or dependent edema. Pericardial effusion is fluid accumulation within the membrane around the heart.
A patient's osmoreceptors are stimulated. Which action does the nurse take? Provide oxygen Provide quiet time Provide salty foods Provide a glass of water
Provide a glass of water Increased osmolality stimulates hypothalamic osmoreceptors. In addition to causing thirst, these osmoreceptors signal the posterior pituitary gland to release antidiuretic hormone. Thirst stimulates water drinking. Salty foods would make the situation worse. Quiet time and oxygen are not needed.
Which fluid does the nurse measure as intake? Urine Stool Insensible water loss Water and other beverages that the patient drinks
Water and other beverages that the patient drinks Rationale Water obtained by drinking, water ingested in food, and water derived from oxidative metabolism are the primary sources of body water intake. Urine, stool, and insensible water loss are examples of fluid output.
Which situation causes the nurse to closely monitor a patient for hypokalemia? Diarrhea Oliguric renal failure Hyperparathyroidism Diabetic ketoacidosis
diarrhea Diarrhea increases the amount of potassium lost in the feces, making one predisposed to hypokalemia. In diabetic ketoacidosis, extracellular hydrogen ions move into the cell in exchange for intracellular potassium, which results in hyperkalemia. Oliguric renal failure decreases potassium excretion and leads to hyperkalemia. Parathyroid hormone regulates changes in calcium concentration, not potassium concentration.
A nurse teaches about the process responsible for movement of water between the patient's interstitial and intracellular compartments. Which process is the nurse describing? Diffusion Osmosis Filtration Active transport
osmosis Rationale Movement of water between the interstitial and intracellular compartments occurs by the process of osmosis. Filtration is responsible for the distribution of fluid between the vascular and interstitial compartments. Diffusion involves movement of particles, not movement of water. Active transport moves ions across membranes, but it does not move wate
A patient is acidotic (has acidosis). Which result does the nurse observe when reviewing arterial blood results? Excess of base pH less than 7.35 pH greater than 7.45 Decrease in hydrogen ion concentration
pH less than 7.35 Rationale Acidosis is a state in which the pH of arterial blood is less than 7.35. A systemic loss of base or increase in hydrogen ion concentration is called acidosis. Alkalemia is a state in which the pH of arterial blood is greater than 7.45 or there is an excess of base.
"My feet swell if I eat salt," says a patient who has chronic compensated heart failure, "so I stopped eating it like my nurse practitioner said, but I don't understand how salt causes swelling." What is the nurse's best response? "Salt makes your blood vessels relax and the blood does not flow as fast, so some of it leaks into your tissues and makes swelling." "Salt binds to the proteins in your blood and changes the osmotic pressure so more fluid can leak out and stay in the tissues, causing swelling." "Salt holds water in your blood and makes more pressure against your blood vessels, so fluid leaks out into your tissues and makes them swell." "Salt is not the problem, gravity makes more pressure down by your feet than up at the top of your body, so more fluid leaks into your tissues at your feet and they swell."
"Salt holds water in your blood and makes more pressure against your blood vessels, so fluid leaks out into your tissues and makes them swell." Rationale The movement of water between ICF and ECF compartments is primarily a function of osmotic forces. Sodium is responsible for the osmotic balance of the ECF space. Congestive heart failure, renal failure, and cirrhosis of the liver are associated with excessive salt and water retention, which causes plasma volume overload, increased capillary hydrostatic pressure, and edema. Salt does not cause vasodilation. Salt does not bind to blood proteins and change osmotic pressure. Gravity does affect edema, but saying salt is not the problem is inaccurate.
A nurse weighs a patient. Which principle does the nurse remember? 1 liter of water weighs 2.2 lb (1 kg). 2 liters of water weigh 2.2 lb (1 kg). 3 liters of water weigh 2.2 lb (1 kg). 4 liters of water weigh 2.2 lb (1 kg).
1 liter of water weighs 2.2 lb (1 kg). Rationale 1 liter of water weighs 2.2 lb (1 kg). Thus 2 liters would weigh 4.4 lb (2 kg); 3 liters would weigh 6.6 lb (3 kg); and 4 liters would weight 8.8 lb (4 kg).
A patient weighed 142.4 lb yesterday. The nurse weighs the patient today and obtains a weight of 146.8 lb. How many liters of fluid did the patient retain? 1 L 2 L 4.4 L 5.4 L
2 L Rationale One liter of water weighs 2.2 lb (1 kg). The patient gained 4.4 lb (146.8 - 142.4 = 4.4). A weight of 4.4 lb is equal to 2 liters of water (4.4 ÷ 2.2 = 2). One liter would be if the patient only gained 2.2 lb; 4.4 L and 5.4 L are too high.
Which electrolyte imbalance is the patient experiencing (see chart)? lab results: total calcium 6.5 potassium 4.5 increased neuromuscular excitability tingling muscle spasms pulse 86 RR 16 Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia
Hypocalcemia Rationale Hypocalcemia is a low blood calcium level (less than 8.5 mg/dl) and causes increased neuromuscular excitability, tingling, and muscle spasms. Vital signs are normal. The potassium level is normal (3.5 to 5.0 mEq/L). Hypercalcemia would be a high blood calcium level (greater than 10 to 12 mg/dl) and would cause other signs and symptoms.
A patient has isotonic fluid excess. Which treatment does the nurse prepare to implement? Increase fluids. Replace potassium. Administer diuretics. Slow breathing down.
Administer diuretics. Rationale Diuretics are commonly used for treatment of isotonic fluid excess. Increasing fluids would make the problem worse. Replacing potassium is needed for hypokalemia, not isotonic fluid excess. Slow breathing helps with hyperventilation but not with isotonic fluid excess.
The nurse plans care for a patient with a serum potassium level of 3.0 mEq/L. The care includes which treatment directions? Administer insulin intravenously at 30 units/hr. Administer sodium intravenously at 50 mEq/hr. Administer cation exchange resin at 10 units/hr. Administer potassium intravenously at 20 mEq/hr.
Administer potassium intravenously at 20 mEq/hr. Rationale A maximal safe rate of intravenous potassium replacement is 20 mEq/hr. A potassium level of 3.0 is hypokalemia. Administering insulin and cation exchange resin (which is not given in units) would cause the potassium to lower even further; in fact, these treatments are contraindicated for hypokalemia. Sodium would not help with hypokalemia.
A patient has a serum sodium concentration below 134 mEq/L. What term does the nurse use to describe this condition? Hypokalemia Hyperkalemia Hyponatremia Hypernatremia
Hyponatremia Rationale Hyponatremia, not hypernatremia, develops when the serum sodium concentration falls below 135 mEq/L. Hyperkalemia and hypokalemia refer to potassium, not sodium.
Which substances does the nurse include when teaching about the kidney's ability to properly maintain a patient's serum pH? Select all that apply. Sodium (Na +) Potassium (K +) Ammonia (NH 3) Phosphate (HPO 4 2-) Bicarbonate (HCO 3 -) Carbonic acid (H 2CO 3)
Ammonia (NH 3) Phosphate (HPO 4 2-) Bicarbonate (HCO 3 -) Carbonic acid (H 2CO 3) Rationale The distal tubule of the kidney regulates acid-base balance by secreting hydrogen into the urine and reabsorbing bicarbonate. Dibasic phosphate (HPO 42-) and ammonia (NH 3) are two important renal buffers. The renal buffering of hydrogen ions requires the use of carbon dioxide (CO 2) and water (H 2O) to form carbonic acid (H 2CO 3). Sodium and potassium do not contribute to the activity of the renal buffering system.
A nurse explains vasopressin to a patient who needs to take a new medication. What is the nurse describing? Sodium Aldosterone Natriuretic peptides Antidiuretic hormone
Antidiuretic hormone. Rationale Water balance is regulated primarily by antidiuretic hormone (also known as vasopressin). Aldosterone is a hormone that regulates sodium. Sodium is the major extracellular ion. Natriuretic peptides are hormones produced by the myocardial atria and cause increased sodium and water excretion, decreasing blood pressure.
A patient has an edematous leg. Which action does the nurse take? Encourage standing Apply compression stockings Suggest increasing the salt intake Keep the leg in a dependent position
Apply compression stockings Rationale Edema may be treated symptomatically until the underlying disorder is corrected. Supportive measures include elevating edematous limbs, using compression stockings, avoiding prolonged standing, restricting salt intake, and taking diuretics. Standing, increased salt intake, and keeping the leg in a dependent position are all contraindicated.
What can absorb excessive H + (acid) or OH - (base) without a significant change in the patient's plasma pH? Buffers Calcium Potassium Magnesium
Buffers Rationale Buffers, not calcium, potassium, or magnesium, can absorb excessive H + (acid) or OH - (base) without a significant change in pH.
Which term does the nurse use to describe a patient's major buffer in the extracellular fluid? Protein Phosphate Hemoglobin Carbonic acid-bicarbonate
Carbonic acid-bicarbonate Rationale The carbonic acid—bicarbonate buffer pair operates in both the lung and the kidney and is a major extracellular buffer. Proteins are intracellular buffers. Hemoglobin is an intracellular buffer. Phosphate is an important element in the renal buffer system.
The nurse expects a patient with a serum sodium level of 120 mEq/L to have which assessment findings? Confusion and lethargy Thirst and dry mucous membranes Neuromuscular irritability and diarrhea Hyperactive bowel sounds and intestinal cramping
Confusion and lethargy Rationale Clinical manifestations of hyponatremia (levels below 135 mEq/L) include confusion, lethargy, coma, and perhaps seizures. Thirst and dry mucous membranes are associated with a water deficit and hypernatremia. Hyperactive bowel sounds and intestinal cramping are signs of hypocalcemia. Neuromuscular irritability and diarrhea occur with hyperkalemia. Most individuals are asymptomatic. Neurologic symptoms occur with severe hyponatremia (i.e., decreases less than 125 mEq/L) and include lethargy, headache, confusion, apprehension, seizures, and coma.
A patient has drainage from an intestinal fistula that is being managed at home while it heals. A home health nurse visits regularly to change the dressing. Today the patient is already lying down when the nurse arrives, complaining of feeling "weak and dizzy" when standing up. Supine blood pressure is 92/70, and the heart rate is 78. When the patient sits up, the patient slumps sideways and is temporarily unresponsive. Systolic blood pressure was 77 before the patient fell sideways, and the heart rate was very fast. The patient has regained consciousness. What is the most appropriate action by the nurse before contacting the patient's primary healthcare provider? Give the patient water to drink. Assess for ankle edema and pulses. Place the patient in a sitting position. Ask if the patient slept well last night.
Give the patient water to drink. Rationale Treatment for water deficit is to give water and stop fluid loss. The patient has postural hypotension from hypovolemia. Ankle edema occurs with fluid excess, not deficit. How a patient sleeps at night will not help with water deficit. Placing the patient in a sitting position will make the problem worse, as seen when the patient became unresponsive when sitting up.
A patient with oliguria from renal failure is closely monitored by the nurse for which electrolyte imbalance? Hypokalemia Hyperkalemia Hypercalcemia Hypophosphatemia
Hyperkalemia Rationale The oliguric phase of renal failure decreases potassium excretion, which causes hyperkalemia. Hypokalemia would not occur in renal failure. Hypocalcemia and hyperphosphatemia occur in patients with chronic renal failure.
A patient has an inadequate intake of dairy products and green leafy vegetables. Which condition does the nurse monitor in this patient? Hypercalcemia Hypernatremia Hypocalcemia Hyponatremia
Hypocalcemia Rationale A diet low in dairy products and green leafy vegetables would lead to hypocalcemia, not hypercalcemia. Hypernatremia or hyponatremia (sodium imbalances) would not be caused as readily as this calcium imbalance.
Which patient situation leads to the development of respiratory acidosis? Vomiting Tissue hypoxia Hypoventilation Hyperventilation
Hypoventilation Rationale Hypoventilation causes CO 2 retention and respiratory acidosis. Vomiting can lead to metabolic alkalosis by stimulating renal retention of bicarbonate and loss of hydrochloric acid (HCl). Tissue hypoxia causes lactic acid production, leading to metabolic acidosis. Hyperventilation causes excretion of too much CO 2 and leads to respiratory alkalosis.
A patient has an acid-base imbalance. The nurse expects the patient's renal buffering system to respond in which manner? If metabolic alkalosis exists, the kidneys eliminate CO 2. If metabolic acidosis exists, the kidneys eliminate CO 2. If metabolic acidosis exists, the kidneys conserve H + ions. If metabolic alkalosis exists, the kidneys conserve H + ions.
If metabolic alkalosis exists, the kidneys conserve H + ions. Rationale If metabolic alkalosis exists in the body, the kidneys conserve H + ions to allow acid to accumulate to normal levels. If metabolic acidosis exists in the body, the kidneys do not conserve H + ions; they eliminate them. The lungs control the level of CO 2, not the kidneys.
Which term does the nurse use to describe the fluid located within the patient's cells? Interstitial Intracellular Extracellular Intravascular
Intracellular Rationale Intracellular fluid comprises all the fluid within cells, about two thirds of total body water (TBW). Extracellular fluid (ECF) is all the fluid outside the cells (about one third of TBW) and is divided into smaller compartments. The two main ECF compartments are the interstitial fluid (the space between cells and outside the blood vessels) and the intravascular fluid (blood plasma).
A patient's laboratory test results reveal decreased arterial pH and bicarbonate levels. The nurse interprets these results to determine the patient is experiencing which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis Rationale Decreases in arterial pH and bicarbonate occur with metabolic acidosis. Metabolic alkalosis occurs if pH and bicarbonate levels are elevated. Respiratory acidosis occurs when pH is decreased and carbon dioxide is elevated, whereas respiratory alkalosis occurs when pH is elevated and carbon dioxide is decreased.
The nurse assesses a patient with diarrhea for clinical manifestations of which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis Rationale Diarrhea causes metabolic acidosis through bicarbonate excretion. Vomiting can cause metabolic alkalosis. Diarrhea causes a metabolic acid-base imbalance rather than a respiratory one.
A patient has respiratory alkalosis and develops carpopedal spasms. What does the nurse observe upon assessment? Muscle spasms in the face and neck Muscle spasms in the fingers and toes Muscle spasms in the abdomen and back Muscle spasms in the chest and shoulders
Muscle spasms in the fingers and toes Rationale Carpopedal spasms are spasms of muscles in the fingers and toes. The spasms do not occur in the face, neck, abdomen, back, chest, or shoulders.
Which patient is most susceptible to dehydration? One that is lean One that is obese One that has little body fat One that is within normal weight
One that is obese Rationale Individuals with more body fat have proportionately less total body water (TBW) and tend to be more susceptible to dehydration. Those that are lean or have little body fat have a higher level of TBW than persons with normal weight or obesity. A person with normal weight has a higher TBW percentage in relation to those with obesity but a lower percentage than a person who is lean.
A child has a diagnosis of starvation ketoacidosis (a metabolic acidosis). What clinical manifestations does the nurse anticipate when assessing the child? Rapid, deep breathing, lethargy, abdominal pain Slow, shallow breathing, belligerence, hyperexcitability Rapid, deep breathing, tremors, attention deficit disorder Slow, shallow breathing, numbness and tingling around the mouth
Rapid, deep breathing, lethargy, abdominal pain Rationale Rapid, deep breathing, lethargy, and abdominal pain are clinical manifestations of metabolic acidosis and its respiratory compensation. Slow, shallow breathing, belligerence, hyperexcitability, attention deficit disorder, and numbness and tingling around the mouth are not clinical manifestations of metabolic acidosis and its respiratory compensation. Tremors and elevated blood pressure are not clinical manifestations of metabolic acidosis.
A nurse uses the diagram (see picture) while teaching a patient. Which alteration is the nurse describing?
Rationale Hypertonic alteration is an increase in extracellular fluid (ECF) sodium concentration (hypernatremia) that results in osmotic attraction of water out of the cells, causing cell shrinkage. Hypotonic alteration is a decrease in ECF sodium (Na) concentration (hyponatremia), resulting in intracellular fluid osmotic attraction of water with swelling and potential bursting of cells. Isotonic alteration is the normal concentration of sodium in the ECF and no change in shifts of fluid in or out of cells. The word intertonic does not have any physiology- or medicine-related sense
A nurse teaches the basics of fluid and electrolytes to the staff. The nurse asks: Which ion has a higher concentration in the patient's major extracellular fluid than in the patient's intracellular fluid? Sodium Potassium Phosphate Magnesium
Sodium Rationale Extracellular fluid has a higher sodium ion concentration than does intracellular fluid. Intracellular fluid has a higher concentration of potassium ions, phosphate ions, and magnesium ions than does extracellular fluid.
A child has been vomiting for 2 days. The nurse's assessment of the child finds a rapid pulse, dry mouth, decreased skin elasticity, and irritability. How does the nurse interpret these assessment findings? The child is severely dehydrated. The child is overhydrated with water. The child has developed metabolic acidosis. The child has developed respiratory alkalosis.
The child is severely dehydrated. Rationale The vomiting has led to fluid deficit or dehydration. Dry mouth, decreased skin elasticity, irritability, and rapid pulse are all signs of dehydration. Vomiting would lead to metabolic alkalosis, not acidosis. Respiratory alkalosis is a result of fast, rapid breathing.
The nurse completes the health history for a newly admitted patient. Which factors increase the patient's risk for hypokalemia? Select all that apply. The patient has diarrhea. The patient is taking a diuretic. The patient has chronic alcoholism. The patient's serum potassium level is 5.2 mEq/L. The patient has an adequate intake of fruits and vegetables.
The patient has diarrhea. The patient is taking a diuretic. The patient has chronic alcoholism. Rationale Hypokalemia is low potassium and is caused by diuretics, diarrhea, alcoholism, and alkalosis. A serum level of 5.2 mEq/L is elevated. An adequate intake of fruits and vegetables will not lead to hypokalemia; an inadequate intake can lead to hypokalemia.
A nurse monitors a patient's intake and output. Which area has the highest volume of daily fluid loss? Skin Stool Urine Lungs
Urine Rationale The largest volume of fluid is excreted in the urine (1400 to 1800 ml/day). Fluid loss via the skin is 300 to 500 ml/day. The lung's loss is 600 to 800 ml/day. About 100 ml/day is lost via the stool.
