Lewis Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse?
Blood pressure is 90/40 mm Hg.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?
"Increase the fluids if your mouth feels dry."
A pregnant patient with eclampsia is receiving IV magnesium sulfate. Which finding should the nurse report to the health care provider immediately?
The patellar and triceps reflexes are absent.
A student asks the nurse why a peripherally inserted central catheter is needed for a patient receiving parenteral nutrition with 25% dextrose. Which response by the nurse is accurate?
"The hypertonic solution will be more rapidly diluted when given through a central line."
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
"I will drink apple juice instead of orange juice for breakfast."
A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
Administer the prescribed fluid bolus and insulin.
A patient with new-onset confusion and hyponatremia is being admitted. Which action should the charge nurse take when making room assignments?
Assign the patient to a room near the nurse's station.
After placement of a centrally inserted IV catheter, a patient reports acute chest pain and dyspnea. Which action should the nurse take first?
Auscultate the patient's breath sounds.
A patient who comes to the clinic reports frequent, watery stools for 2 days. Which action should the nurse take first?
Check the patient's blood pressure.
A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?
Daily alcohol intake
A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance?
Daily weight
A patient who has been hospitalized for 2 days has a nasogastric tube to low suction and is receiving normal saline IV at 100 mL/hr. Which assessment finding would be a priority for the nurse to report to the health care provider?
Decreased alertness since admission
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved?
Decreased peripheral edema
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
Digoxin (Lanoxin) 0.25 mg/day
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. Which clinical manifestation should the nurse expect?
Edema
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
Encourage fluid intake up to 4000 mL daily.
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/VN)?
Flush a saline lock with normal saline.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient reports anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
Give the patient the PRN IV morphine sulfate 4 mg.
A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
Infuse 5% dextrose in water intravenously at 125 mL/hr.
IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action should the nurse take?
Infuse the KCl at a maximum rate of 10 mEq/hr.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
Lung sounds
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications. The patient seems confused and short of breath with peripheral edema. Which assessment should the nurse complete first?
Mental status
A patient who is lethargic and with deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 35 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
Metabolic acidosis
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse expect to take first?
Monitor ionized calcium level.
An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
Na+ 154 mEq/L (154 mmol/L)
A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?
Notify the patient's health care provider.
After receiving change-of-shift report, which patient should the nurse assess first?
Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
Respiratory alkalosis
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
Serum calcium is 18 mg/dL
A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
Serum sodium of 120 mg/dL
A patient with renal failure is on a low phosphate diet. Which food should the nurse instruct unlicensed assistive personnel (UAP) to remove from the patient's food tray?
Skim milk
A patient who is taking a potassium-wasting diuretic for treatment of hypertension reports generalized weakness. Which action is appropriate for the nurse to take?
Suggest that the health care provider order a basic metabolic panel.
Following a thyroidectomy, a patient reports "a tingling feeling around my mouth." Which assessment should the nurse complete first?
Test for presence of Chvostek's sign.
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
The patient is experiencing stridor.
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
There are crackles throughout both lung fields.
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
Use the push-pause method to flush the CVAD after giving medications.
