F & E - Nur1034
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?
Chest pain Explanation: 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.
Which of the following solutions is hypotonic?
0.45% NaCl Explanation: Half-strength saline is hypotonic. Lactated Ringer's solution is isotonic. Normal saline (0.9% NaCl) is isotonic. A solution that is 5% NaCl is hypertonic.
A client's arterial blood gas values are shown. The nurse should develop a care plan based on the fact the client is experiencing which clinical situation?
metabolic acidosis Explanation: The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3- level is decreased. These findings indicate that the client is in metabolic acidosis.
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?
50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.
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 52-year-old with diarrhea Explanation: 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 patients will not likely have an electrolyte imbalance. Myocardial infarction patients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
A nurse is caring for a client with dehydration. Which of the following signs are observed in a client with dehydration? Select all that apply.
Skin turgor over sternum Decreased blood pressure Low urine output Explanation: The nurse should note skin turgor, decreased blood pressure, and low urine output in a client with dehydration. The client's pulse and respiratory rate would decrease, instead of increase, with dehydration.
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?
Tachycardia Explanation: 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.
The nurse is caring for a 12-month-old infant with dehydration and metabolic acidosis. What symptom does the nurse document as congruent with dehydration and metabolic acidosis?
Tachypnea. Explanation: The nurse would expect to see tachypnea because the body compensates for metabolic acidosis via the respiratory system, which tries to eliminate carbon dioxide by increasing alveolar ventilation through deep, rapid respirations. The cardiovascular symptoms the nurse would observe would be poor perfusion, weak pulses and tachycardia, not bradycardia. The child may also be hypotensive but unless there is a respiratory disorder or polycythemia, the nurse would not expect to see cyanosis.
Which of the following is considered an isotonic solution?
0.9% normal saline. An isotonic solution is 0.9% normal saline (NaCl). Dextran in NS is a colloid solution, 0.45% normal saline is a hypotonic solution, and 3% NaCl is a hypertonic solution.
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?
Dark, concentrated urine. Explanation: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.
An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?
Hypokalemia Explanation: Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a defict in total potassium stores. Potassium-losing diuretics, such as loop diuretics, can induce hypokalemia.
Which of the following individuals with diarrhea for 3 days are more likely to suffer from fluid and electrolyte imbalance?
Infant Explanation: The very young child and older adults are at greatest risk for fluid or electrolyte imbalances.
A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe?
Infiltration Explanation: Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and significant decrease in the flow rate. The signs of sepsis include red and tender insertion site, fever, malaise, and other vital sign changes. The symptoms of thrombus are local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.
A nurse is caring for a patient who has burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this patient?
Lactated Ringer's solution Explanation: Lactated Ringer's solution is a roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43-). It is used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea and in treating mild metabolic acidosis.
The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?
Potassium: 5.8 mEq/L Explanation: Normal potassium level is 3.5 to 5.5 mEq/L. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn, yielding the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?
Respiratory acidosis Explanation: The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, respiratory acidosis exists and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube on low continuous suction. Which acid-base imbalance is most likely to occur?
metabolic alkalosis Explanation: Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.
The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour × drop factor (gtt/mL) time (60 min)
100 gtt/min Explanation: 100gtt/min is the correct rate. 1000 mL divided by10 hours= 100 mL per hour x 60 gtt/minute, divided by 60 minutes.
A nurse flushing a capped peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation?
Aspirate and attempt to flush the line again. Explanation: If the IV does not flush easily: Assess insertion site. Infiltration and/or phlebitis may be present. If present, remove and restart in another location. In addition, the catheter may be blocked or clotted due to a kinked catheter at the insertion site. Aspirate and attempt to flush again. If resistance remains, do not force. Forceful flushing can dislodge a clot at the end of the catheter. Remove and restart in another location. If assessment reveals the catheter has pulled out a short distance, do not reinsert it; it is no longer sterile. Remove and restart in another location.
A 73-year-old male client was admitted to your hospital unit after 2days of vomiting and diarrhea. His wife became alarmed when he demonstrated confusion and elevated temperature and reported "dry mouth." You suspect the client is experiencing which of the following conditions?
Dehydration. Explanation: Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. The most common fluid imbalance in older adults is dehydration. Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from excessive oral intake or rapid IV infusion of fluid. Early signs of hypervolemia are weight gain, elevated BP, and increased breathing effort. Hypercalcemia occurs when the serum calcium level is higher than normal. Some of its signs include tingling in the extremities and the area around the mouth (circumoral paresthesia) and muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the blood. Symptoms include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias.
A priority nursing intervention for a client with hypervolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications. Explanation: Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.
Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL. For what assessment findings will you be looking?
Muscle cramping and tetany Explanation: Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.
A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/l. Should the nurse start salt tablets when caring for this client?
No, sodium intake should be restricted. Explanation: 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.
Upon assessment of a patient's peripheral intravenous site, the nurse notices the area is red and warm. The patient complains of pain when the nurse gently palpates the area. What are these signs and symptoms indicative of?
Phlebitis Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.
A 75-year-old client who complains of a "sour stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for what acid-base imbalance?
metabolic alkalosis Explanation: Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. Regular use of baking soda (sodium bicarbonate) may place the client at 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.
A client appears flushed and has shallow respirations. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial carbon dioxide (PaCO2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3-), 24 mEq/L (24 mmol/L). These findings are indicative of which acid-base imbalance?
respiratory acidosis Explanation: The pH of 7.24 indicates that the client is acidotic. The PaCO2 value of 49 mm Hg is elevated. The HCO3- value of 24 mEq/L is normal. The client is in uncompensated respiratory acidosis. Hypoventilation and a flushed appearance are additional clinical manifestations of respiratory acidosis.
The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be which of the following?
155 mEq/L Explanation: The patient is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's
Low calcium Explanation: Normal total serum calcium levels range between 8.9 and 10.1 mg/dL.
A client has these arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition?
respiratory acidosis Explanation: This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In metabolic alkalosis, the pH and HCO3- values are above normal.
