Fluid and Electrolytes
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?
"Let me refer you to the blood bank so they can provide you with information." Explanation: Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be reinfused.
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.
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 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.
The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients?
Cardiac volume intolerance Explanation: The older adult client is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. Older adults typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.
Which electrolyte is a major cation in body fluid?
Potassium Explanation: Potassium is a major cation that affects cardiac muscle functioning. Chloride, bicarbonate, and phosphate are anions.
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?
pH: 7.60; PaCO2: 64; HCO3: 42 Explanation: In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high HCO3, such as 64; and a high PaCO2, such as 42. The numbers correlate with metabolic alkalosis, which is indicated by the hyperventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis.
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:
respiratory alkalosis. Explanation: 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.
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?
"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."
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)?
Active transport Explanation: 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.
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?
Calcium Explanation: 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.
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 Explanation: 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.
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 water as an inexpensive way to meet fluid needs. Respond to thirst Explanation: 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.
An older adult client with dehydration repeatedly tells the nurse, "I am just not thirsty. I don't want anything to drink." Which nursing actions are appropriate? Select all that apply.
Identify fluid preferences. Offer fluids at times other than meals. Offer small amounts of preferred liquids frequently. Explanation: Older adults may need to be encouraged to drink fluids, even at times when they do not feel thirsty, because age-related changes may diminish the sensation of thirst. Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. To maintain adequate consumption of nutrients, it is best to offer fluids to older adults at times other than meals. Encourage older adults to drink noncaffeinated beverages because of the diuretic effect of caffeine or to replace the volume of caffeinated beverages by consuming the same volume of noncaffeinated fluids per day. The nurse should never initiate intravenous fluid replacement without an order.
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?
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.
Mr. Jones is admitted to the nursing 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 should the nurse be alert?
Muscle weakness, fatigue, and dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. 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 client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?
Remove the IV. Explanation: The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?
pH 7.48 Explanation: 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.
