Chapter 39: Fluid, electrolyte & acid-base balance
Phosphorus
2.5-4.5
Bicarbonate
25-29
Potassium
3.5-5.0
Calcium
8.6-10.2
Chloride
97-107
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?
Sodium is regulated by the renin-angiotensin-aldosterone system.
Which client would be a candidate for total parenteral nutrition?
a client with colitis and bloody diarrhea
A client with dehydration will have an increase in:
aldosterone
The process of filtration begins at the:
glomerulus.
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?
"I've been taking antacids almost every 2 hours over the past several days."
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?
2,500 mL/day
Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations will you be alert?
Muscle weakness, fatigue, and dysrhythmias
Magnesium
1.3-2.3
The nurse is monitoring intake and output (I&O;) for a client who has diarrhea. What will the nurse document as input on the I&O;record? (Select all that apply.)
100 mL from melted ice chips serving of jello infusion of intravenous solution cup of ice cream The nurse will document all fluid intake and fluid loss. This includes drinking liquids and intravenous fluids. The liquid equivalent of melted ice chips is fluid intake. Foods that are liquid by the time they are swallowed, such as gelatin, ice cream, and thin cooked cereal, are documented as fluid intake.
Sodium
135-145
A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply.
A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply. An increase in pulse rate of more than 20 beats per minute is a more sensitive indicator of ECF volume deficit than is a decrease in blood pressure. A drop of more than 15 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with an increase in pulse rate frequently means the client is experiencing ECF volume depletion.
The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?
Diarrhea
A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply.
Metabolic alkalosis Hypokalemia If sufficient gastric juice (ECF with additional acid) is lost from the stomach, then consequently hydrogen, sodium, and chloride ions are depleted, increasing the risk of ECF volume deficit and/or metabolic alkalosis. Gastric fluid also is high in potassium, and excessive losses may contribute to hypokalemia.
When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which guideline should the nurse follow?
Use distal veins before proximal veins.
An increase in pulse rate of more than 20 beats per minute is a more sensitive indicator of ECF volume deficit than is a decrease in blood pressure. A drop of more than 15 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with an increase in pulse rate frequently means the client is experiencing ECF volume depletion.
blood pressure 100/48 mm Hg poor skin turgor heart rate 128/bpm Fluid volume deficit causes a low BP (100/48 mm Hg), poor skin turgor, and an elevated heart rate (128/bpm). Fluid excess can cause crackles and distended neck veins.
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phosphorus The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances.
When providing care for a client who has a peripheral intravenous catheter in situ, the nurse should:
change the site every three to four days. Peripheral IV sites should be rotated every 72 to 96 hours, depending on the institutional protocol. IV insertion sites are not cleansed daily. Flushes are not necessary every six hours. Hypertonic solution is not used for IV flushes. The smallest gauge that is practical should be inserted in order to minimize trauma.
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:
electrolytes.
Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?
febrile reaction Febrile reaction to blood components can occur because of the recipient's hypersensitivity to the donor's white blood cells. In this reaction, the client develops a fever and chills and may complain of a headache and malaise.
Parathyroid gland
Regulates Calcium and Phosphate levels in the blood by secreting PTH More PTH= More calcium and less Phosphate Less PTH=Less Calcium and more Phosphate
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? (Select all that apply.)
The nurse knows that clients with major trauma or burns, clients with liver and renal failure, and clients with inflammatory bowel disease are likely candidates for TPN.
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?
The pump will continue to infuse fluid even when the needle is displaced.
Which statement accurately describes a guideline when using an implanted port venous access device?
The system is accessed with a noncoring needle and patency is maintained by periodic flushing.
A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?
To prevent compromising circulation
A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?
fluid volume excess and acidosis Fluid volume excess can be caused by malfunction of the kidneys (i.e., renal failure). The kidneys are also responsible for acid-base balance, and in the presence of renal failure, the kidneys cannot regulate hydrogen ions and bicarbonate ions, so the client develops metabolic acidosis.
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?
maintenance of cell size The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.
The passageways of the kidney permit the urine to flow to the bladder and:
selectively reabsorb or secrete substance to maintain fluids and electrolytes.
