Fundamentals of Nursing III (Chap 39 Fluid, Electrolyte, and Acid-Base Balance Prep U)
What commonly used IV solution is hypotonic?
0.45% NaCl (normal saline & Lactated Ringer's are isotonic, 5% dextrose in 0.45% NaCl is hypertonic)
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's lab studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
Calcium & Phosphorus (the parathyroid gland secretes parathyroid hormone, which regulates the level of calcium & phosphorus
A client admitted with heart failure requires careful monitoring of his fluid status. What assessment parameter will provide the nurse with the best indication of the client's fluid status?
Daily weights
When a client age 80 years takes diuretics for management of hypertension tells the nurse that she takes laxatives daily to promote bm's, the nurse asses the client for possible symptoms of what?
Hypokalemia (frequent use of laxatives & diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid & electrolyte deficits)
Endurance athlete's who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. What is this electrolyte balance known as?
Hyponatremia (extracellular fluid caused by a loss of sodium or gain of water)
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
an implanted central venous access device (CVAD). Implanted CVAD's are ideal for long-term uses such as chemotherapy
Which client is at risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
an infant age 4 mos, an infant has considerably more body fluid and extracellular fluid (ECF) than an adult has, because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits
When caring for a client who is on IV therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. What intervention should the nurse perform for this complication?
apply a warm compress. prolonged use of the same vein can cause phlebitis, the nurse should apply a warm compress after restarting the IV
A home care nurse is teach a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies what as a rich source of potassium?
apricots (they are a rich source of potassium)
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse "I get thirsty often, what might help?" What would the nurse include as a suggestion for this client?
avoid salty or excessively sweet fluids (to minimize thirst in a client on fluid restriction)
The nurse is caring for a male client who has a diagnosis of heart failure. Today's lab results show a serum potassium of 3.2 mEq/L. What complications should the nurse be aware of related to the potassium level?
cardiac dysrhythmias (typical signs of hypokalemia include: muscle weakness, leg cramps, fatigue, paresthesias, and dysrhythmias)
A client's most recent bloodwork indicates a K+ level of 7.2 level of mEq/L, a finding that constitutes hyperkalemia. What signs and symptoms should the nurse vigilantly monitor?
cardiac irregularities (hykalemia compromises the normal functioning of the sodium-potassium pump and action potentials). The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias
When providing care for a client who has a peripheral IV catheter in situ, the nurse should do what?
change the site every 3 to 4 days (peripheral IV sites should be rotated every 72 to 96 hrs depending on the institutional protocol)
A client who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration (located in the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume)
The nurse reviews the lab 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 GI system?
diarrhea
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 the client needs restoration of?
electrolytes
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 & acidosis (fluid volume excess can be caused by malfunction of the kidneys (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)
The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the clients feet and ankles bilaterally. This assessment finding is suggestive of what?
fluid volume excess (edema is a characteristic sign of fluid volume excess, hypervolemia)
ABG's reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?
increased respiratory rate (hyperventilation results in CO exhalation and a consequent increase in pH, with the goal attaining the ideal of 7.35 to 7.45
A client is diagnosed with metabolic acidosis. The nurse develops a plan of care based on the understanding that the body compensates for this condition by what?
increasing ventilation through the lungs
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation?
notify the primary care provider immediately for possible fluid overload
Upon assessment of a client's peripheral IV site, the nurse notices the area is red & warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of what?
phlebitis (phlebitis is an infection at the local site of an IV catheter
A woman of 58 yrs is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hrs. Her BP is 88/50 and she is diaphoretic. She requires what?
replacement of fluids for those lost from vomiting and diarrhea
The nurse is assessing a newly admitted client and finds that he has edema in his right ankle that is 2 mm and is just perceptible. The nurse documents this at which grade?
the edema in the client should be graded as +, which means the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4-6 mm. A measurement of 4+ indicates severe edema of 8 mm or more
What statement most accurately describes the process of osmosis?
water moves from an area of lower solute concentration to an area of higher solute concentration (osmosis is the primary method for transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water)
