Chapter 18 Fluid and Electrolytes
1 mEq of any electrolyte is equal to ?
1 mEq of hydrogen
A nurse on a medical surg unit is caring for a group of patients. Sort those at at risk for hypovolemia or hyper.
Hypo: Nasogastric suction, diuretics Hyper: syndrome of inappropriate antiduretic hormone, cirrhosis
Normal magnesium blood level
1.5-2.5 mEq
Normal sodium blood level
135-145 mEq/L
The nurse demonstrates knowledge by choosing which needle gauge when starting a rapid transfusion of whole blood?
14-16 gauge
The patient is encouraged by his doctor to eat foods that are rich in potassium. Which lunch tray would be best?
Pork cutlet with milk gravy and mushrooms and melon salad
Normal phosphorous blood level
2.4-4.1 mEq
Dehydration can become lethal when a patient looses ______% of their body fluid.
20%
Normal bicarbonate blood level
22-24 mEq
Normal daily water intake and output is approximately how many mL?
2500
The recommendation of water intake and output is how many mLs?
2500 mL
Normal potassium blood level
3.5-5 mEq
How many mL of urine per hour must the kidneys secrete to eliminate waste products from the body?
30
Kidneys must make at least _________of urine to eliminate waste products.
30 ml/h
The patient has an IV infusion of normal saline. The patient reports mild discomfort at the insertion site and the nurse observes the skin is pale, edematous, feels cool to the touch, and the flow rate is sluggish. What would the nurse do?
Discontinue the IV
What is the largest fluid compartment in the body?
Extracellular
Normal calcium blood level
4.5-5.6 mEq
% of body weight for older adults
45-55%
In acute respiratory acidosis, the renal compensatory mechanisms begin to operate within how many hours?
48
% of body weight for twelve years to adult
50-60%
% of body weight for newborn
70-80%
Which patient is at the greatest risk for dehydration?
72 year old obese male with a fever and anorexia
% of body weight for premature baby
90%
Normal chloride blood level
96-106 mEq
Which nursing intervention is the most important in preventing the introduction of microorganisms to the patient when an IV infusion is initiated?
Hand hygiene
While in the delivery room with his wife, the father to be begins to develop an anxiety reaction and lightheadedness. Which intervention does the nurse use to prevent respiratory alkalosis?
Have him breathe into paper bag.
A nurse is performing an assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings?
Hyperthermia Orthostatic hypotension Decreased skin turgor
The nurse is assisting to prepare a nursing care plan for a patient with continuous IV infusions. What is the goal of IV therapy?
Promote and maintain fluid and electrolyte balance
A nurse is teaching a class about fluid imbalances. Sort the following manifestations into hypovolemia and hypervolemia
Hypo: Flat neck veins, sunken eyeballs Hyper: Breath sounds, weight gain, decreased urine specific gravity
Homeostasis of the hydrogen ion concentration in the body fluids is what?
Acid-base balance
The movement of water from a low concentration to an area of higher concentration occurs through which of the following?
Active transport
This is how electrolytes are moved or transported by hydrostatic pressure. This is a type of active transport where electrolytes are moved from an area of higher concentration to an area of lower concentration.
Active transport processes
The patient is experiencing hyperkalemia. What treatment does the nurse anticipate?
Administration of loop diuretics.
The nurse meets resistance while attempting to flush an intermittent saline lock with 10 ml of saline. Which action would the nurse take first?
Assess for kinks or clamped tubing.
The nurse is assessing an older adult and observes dry mucous membranes, increased heart rate, decreased bp, and poor skin turgor. The patient seems mildly confused and continuously asks for water. What would the nurse do first?
Assess the patient for additional signs of dehydration.
The nurse recieves notification from the lab that a patient's potassium level is 6 mEq/L. The nurse has paged the HCP and is awaiting a call back. What would the nurse do first?
Attach the patient to a cardiac monitor.
The nurse is monitoring an older patient who is receiving a fluid bolus for dehydration. The nurse notices that the patient suddenly has a slight cough and seems a little short of breath. The patient reports, "im ok." What would the nurse do first?
Auscultate the lungs and assess for fluid overload.
What type of blood transfusion is it called when patient donates their own blood ahead of time then is infused their own blood if needed after surgery.
Autologous blood transfusion
A nurse is reviewing the med record of the client. The nurse should identify which of the following findings at risk factor for hypocalcemia?
Bariatric surgery diarrhea thyroid cancer
What are the 3 buffers that keep the pH within normal range?
Blood buffers, lungs, and kidneys
The nurse is checking IV sites carefully for signs of infiltration. Which symptoms indicate infiltration at the IV site?
Burning sensation, pain, puffiness at the site.
The nurse is caring for a patient who had surgery on the parathyroid glands. Which electrolyte level in the low normal range is the greatest concern?
Calcium
The nurse is checking the lab data of a woman who is at risk for osteoporosis. Which lab electrolyte value is MOST relevant to this condition?
Calcium level
The patient is on a mechanical ventilation. The arterial blood gases results indicate that the patient has respiratory alkalosis. What would the nurse do first?
Check the ventilator settings and compare to the orders
The nurse offers to take an older neighbor to the grocery store. As they are shopping, the neighbor tells the nurse that, "My doctor told me to watch my salt intake." Which items in the shopping cart would the nurse suggest they put back on the shelf? Select all that apply
Cheddar cheese Ketchup Pretzels Frozen TV dinner
A patients IV has infiltrated. When selecting a site for a new IV line, the nurse should perform which action?
Choose an area proximal to the current site.
An older adult patient is evaluated by the nurse for signs of fluid volume excess in association with IV therapy. Which symptom would indicate fluid volume excess in an elderly patient
Complaints of shortness of breath
The nurse notes that a resident who lives in LTC center has poor fluid intake and spends most of the day dozing in a chair. Based on this observation, which subjective report is the resident most likely to report?
Constipation
The patient needs to have accurate intake and output recorded for every shift. Which sensible fluid losses must be included in the output? Select all that apply.
Diarrhea stools Hemovac drainage Contents from an ileostomy bag Secretions from the nasogastric suction Drainage from indwelling urinary catheter bag
Fluid balance is maintained in the body by which of the following systems? Select all that apply
Respiratory Renal
The patient has been placed on a low sodium diet to assist in the treatment of hypertension. Which patient statement indicates an understanding of the diet teaching?
I use a lot of fresh veggies, although i should give up table salt.
The nurse who is caring for a client with renal failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional s/s would the nurse expect to note in this client?
Increased BP
The nurse is reviewing the data on the client who has hypovolemia. The nurse should identify which of the following findings is a manifestation of hypovolemia?
Increased hct Decreased urine output Increased sodium level
The patient has experienced a prolonged episode of diarrhea. Which clinical observation is consistent with the development of metabolic acidosis?
Increased respiratory rate
What is it called IV solution seeps into the tissues outside the vein?
Infiltration
The nurse is assessing the IV site. If redness, swelling, and warmth are noted, what is likely the cause?
Inflammation and possible phlebitis
What are we preparing for in this situation? Type and cross-match is done first. Vital signs completed before and during infusion. Reactions may happen within the first 15 minutes of transfusion. Always hang a bag of IV normal saline up and connected to a Y IV tubing set.
Initiating a blood transfusion
The nurse is caring for a postoperative patient. Which solution is the HCP most likely to prescribe to replace the fluid deficiency related to the patients NPO status in the pre- and postoperative period?
Isotonic solutions
Fluid leaves the body through what?
Kidneys, lungs, skin, and GI tract
What purposes do the electrolytes serve in the body? Select all that apply.
Maintenance of normal body metabolism Regulation of water balance in the body Regulation of water and electrolyte contents within the cells Formation of hydrochloric acid in gastric juice.
Which acid based imbalance is when blood pH will be below 7.35 and the oxygen readings are within normal limits. Can happen from DKA, hyperventilation, shock, starvation, renal failure, dehydration. Get these people to do deep breathing exercises to help get rid of some CO2 to raise their pH to reduce acidity
Metabolic acidosis
A child has gotten into the medicine cabinet in the home and ingested the remaining contents of an aspirin bottle. Which acid base imbalances does the nurse expect to observe as a result of excessive aspirin ingestion?
Metabolic acidosis and respiratory alkalosis
Which acid based imbalance is when a blood pH will be above 7.45 often caused by vomiting gastric contents, taking too many antacids,
Metabolic alkalosis
What is the best food source for calcium?
Milk
The nurse is caring for a patient with severe hyperkalemia. What actions should be included in the plan of care for the shift?
Monitor serum potassium levels Adminster Kayexalate as prescribed by the HCP Report a urinary output less than 30 ml/h
The nurse is assigned a patient with potassium imbalance. What assessment is most critical for this patient?
Monitor the heart rate and rhythm
The nurse reviews a client's electolyte results and notes that the potassium level is a 5.4 mEq/L. What would the nurse look for on the cardiac moinitor as a reslut of this lab value?
Narrow peaked T waves
The nurse is reviewing the health records of assigned clients. The nurse plan care knowing that which client is at risk for potassium deficit?
Nasogastric suction
A ph of 7 is what?
Neutral
The nurse is supervising a new nurse who will administer IV potassium to a patient. When would the supervising nurse intervene?
New nurse draws dose with a sterile needle and syringe and scrubs the IV insertion port.
The patients potassium level is 5.2. When the nurse discusses dietary selections, the patient should be instructed to limit intake of what food items?
Orange juice Bananas Apples Tomatoes
What stimulates the sensation of thirst?
Osmoreceptors in the hypothalamus
This is the method by which inhaled oxygen is moved into the intravascular compartment. A patient inhales oxygen into the lungs, with the oxygen passing by diffusion into the intravascular compartment?
Passive transport processes
What is inflammation of the vein?
Phlebitis
The nurse hears in report that the patient has been receiving aluminum hydroxide to correct an electrolyte imbalance. Which electrolyte level would the nurse check to evaluate the efficacy of the med?
Phosphorous level
Which acid base imbalance is when too much CO2 is retained so pH drops. Body tries to get rid of the extra CO2 to raise the pH by increasing respirations. RR increases, HR increases, patient is lethargic, confused, dizzy
Respiratory acidosis
Which acid base imbalance is caused by hyperventilation as the lungs low off large amounts of CO2. symptoms are tetany and muscle weakness, tachypnea, and cardiac arrhythmia
Respiratory alkalosis
Following thyroid surgery, the patient reports nausea and a tingling sensation around the nose, mouth, ears, fingers, and toes. The nurse observes muscle spasms in the patient's feet and hands. What is the most important s/s for the nurse to observe for and report?
Respiratory distress
The patient has a medical diagnosis of diabetic ketoacidosis. Which clinical manifestation indicates that the blood buffer system is exhausted?
Respiratory rate is increased
What is it called when a blood infection from poor technique in IV insertion or use of contaminated equipment?
Septicemia
A patient complains of a headache, nausea, vomiting during a blood transfusion. Which action is necessary for the nurse to take immediately?
Stop the blood transfusion Flush the IV line with normal saline
The RN initiates a blood transfusion and then the LPN is assigned to monitor patient. An hour after the transfusion is started, the patient reports nausea, "not feeling right" and demonstrating wheezing. What would the LPN do first?
Stop the transfusion and keep vein open with normal saline.
The nurse is supervising a nursing student who is inserting an IV catheter. Which action prompts the supervising nurse to intervene?
Student looks for vein in the forearm distal to the dialysis shunt
Which patient has the greatest risk for developing hypokalemia?
Takes prescribed loop diuretics
The nurse is reading the PHCP progress notes in the clients health record and sees that the PHCP has documented "insensible fluid loss of approximately 800 ml daily. What client is at risk for this loss?
The fast respiratory rate
It has been 15 minutes since a blood infusion was initiated. What is most indicative that the patient is experiencing a blood transfusion reaction
The patients BP decreases
The patient used excessive antacids, which resulted in serum sodium level of 150 mEq/L. Why would the HCP instruct the nurse to give an IV hypotonic solution?
To correct intracellular dehydration
What is the overall goal of fluid IV administration?
To prevent or correct fluid and electrolyte imbalances
Earlier in the shift a patient with severe diarrhea seemed irritable, anxious, and twitchy. The RN calls from the patient's room and asks that a vial of calcium gluconate, which emergency equipment would the LPN try to quickly obtain for patient with very low calcium?
Tracheotomy tray and resuscitation bag
The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition?
Traumatic burn
The nurse sees that the patient is scheduled to have a potassium supplement. In addition to the last potassium level, what would the nurse assess before administering the potassium?
Urinary output
Potential causes of hypocalcemia may include which conditions? Select all that apply.
Vitmain D deficiency Diuretic use Severe burns Renal failure
What is the best way for the nurse to determine the patients fluid balance?
Weigh the patient daily.
A way to determine water balance is to weigh the patient when?
Weigh them the same time everyday with the same type of clothing.
A central line is preferred over a peripheral IV line under which conditions? Select all that apply
When irritating IV fluids are given When the patient has poor peripheral veins When the patient is to receive chemotherapy
Lower pH a pH of less than 7.35 is what?
acidic
Higher pH a pH of greater than 7.45 is what?
alkaline
The fluids in the interstitial and intravascular compartments are combined to form what compartment?
extracellular
the patient has had chronic obstructive pulmonary disease for a number of years. Which set of arterial blood gas values indicates that the patient is in respiratory acidosis?
pH 7.30, Paco2 50, 02 sat 93%
The patient has had continuous gastric suction. The nurse recognizes that acid base imbalances can occur with this treatment. Which lab data confirms metabolic alkalosis?
pH elevated, Paco2, normal, and HCO3- elevated
