PrepU i hateU Fluid & Electrolytes: Ch. 39
How does the body regulate blood PH? (3 ways)
- _Chemical Buffer Systems_: Molecules (carbolic acid and bicarbonate) attach to H+ or release H+ based on what is needed -_Respiratory_: Medulla senses Acidic blood and increases Respiratory rate and depth, Co2 (from HCo3) is exhaled more making less HCo3 means more alkaline. Medulla sense Basic blood then decreases breathing to keep HCo3, to acidify blood. -_Renal_: Excrete or retain H ions & Bicarbonate. Acidic = release H and retain bicarbonate.
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Position the client on the left side. Apply antiseptic and a dressing. Elevate the client's head. Apply a warm compress.
Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; IRRETATION. the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
How much fluid intake daily? By what methods and how much? How much fluid lost daily? How much and by what?
Fluid Intake daily: 2600ml average. = 1300ml via water intake, 1000ml via food intake, 300ml via *metabolic byproctuction* internally. Fluid lost daily = 2600ml average. = 1500ml via kidneys, 600ml via *skin*, 300ml via *lungs*, 200ml via *feces*.
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. Fluid restriction Electrolyte management Monitoring edema Intravenous therapy Nutrition management Hypervolemia management
Intravenous therapy Electrolyte management Nutrition management Explanation: If a client is at a fluid volume deficit, *intravenous therapy may be ordered by the primary care provider to replenish fluids and electrolytes, /warranting fluid and electrolyte management/*. _Nutrition management may help to increase and maintain electrolyte levels_ by adding foods high in certain electrolytes to the diet. Hypervolemia refers to fluid volume excess. Fluid restriction would be contraindicated because the client is already at a deficit. Edema would be monitored in the case of fluid volume excess.
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? colloid hypertonic hypotonic isotonic
Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell. *osmotic pressure of cell = 250-375 mOsm/L*
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? intravascular interstitial intracellular extracellular
intracellular Explanation: *Intracellular ICF fluid is 70% of total body water.* Extracellular ECF fluid is remaining 30% *Extracellular = Interstital + intravascular fluids* Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment. The dehydration part is just a throw away information.
The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response? "Fluid in the tissue space between and around cells." "Fluid inside cells." "Watery plasma, or serum, portion of blood." "Fluid outside cells."
"Watery plasma, or serum, portion of blood." Explanation: *Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body.* The remaining body fluid is extracellular fluid (fluid outside cells). *Extracellular fluid is further subdivided* into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I should drink 1,500 mL/day of fluid." "I need to drink no more than 1,000 mL/day" "I should drink 2,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid."
*"I should drink 2,500 mL/day of fluid."* Explanation: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? 4+ 1+ 3+ 2+
1+ Explanation: 2, 4, 6, 8 rule +1 = 2mm +2 =4mm +3 =6mm +4 =8mm The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.
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 An increased sense of thirst Increase in nephrons in the kidneys Increased renal blood flow
Cardiac volume intolerance Explanation: Cardiac volume intolerance = decreased ability to handle the volume (pump) 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.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Increased potassium levels Decreased potassium levels Increased sodium levels Decreased oxygen levels
Decreased potassium levels Explanation: Peeing out more means peeing out more electrolytes with it. Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? The client has a decreased sensation of thirst. The renal system retains more water. Urine becomes more diluted. The frequency of voiding increases.
The renal system retains more water. Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. (causes water reabsorbsion) This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.
Potassium is needed for neural, muscle, and: optic function. cardiac function. skeletal function. auditory function.
cardiac function. Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.
Which is a common anion? calcium chloride magnesium potassium
chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.
The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which client actions will the nurse document on the I&O record? Select all that apply. urination infusion of intravenous solution eating a sandwich drinking milk vomiting
drinking milk urination vomiting *infusion of intravenous solution* Explanation: The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and *fluid infusion*. Ingested solids, such as a sandwich, are not included in the intake and output.
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? hypotonic hypertonic isotonic plasma
hypertonic Explanation: Swelling = Bloated cells, bloated with *WATER*. Need to take out the water via osmosis. Hypertonic solution has lots of salt to draw out the water. Done. Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.
What part of the body controls thirst?
hypothalamus
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? muscle cramping and tetany muscle weakness, fatigue, and constipation nausea, vomiting, and constipation diminished cognitive ability and hypertension
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.
*The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?* renal failure diaphoresis increased cardiac output excessive use of laxatives
renal failure diaphoresis = sweating Explanation: Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and *increased cardiac output may lead to a fluid volume deficit.*
The passageways of the kidney permit the urine to flow to the bladder and: -act as a valve that covers the junction between the ureters and the bladder. -surround the Bowman's capsule, which is where the formation of urine begins. -control external sphincter of the urethra and permit the control of urination. -selectively reabsorb or secrete substances to maintain fluids and electrolytes.
selectively reabsorb or secrete substances to maintain fluids and electrolytes. Explanation: The capillaries of the glomerulus are porous, and, as the blood passes through the glomerular capillaries, some constituents of the blood are filtered out.
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 was breathing so fast because I was so anxious and in so much pain." "I've been taking antacids almost every 2 hours over the past several days." "I've had a fever for the past 3 days that just doesn't seem to go away." "I've had a GI virus for the past 3 days with severe diarrhea."
"I've been taking antacids almost every 2 hours over the past several days." Explanation: *DIFFERENCE BETWEEN METABOLIC AND RESPRIATORY alkalosis!* *_Metabolic alkalosis occurs when there is excessive loss of body acids (vomiting or other upper digestion loss, acids there) or with unusual intake of alkaline substances (antacids = anti-acids)_* -BASIC PH-. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, _leads to respiratory alkalosis_. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. *Severe diarrhea is associated with metabolic acidosis.*
Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply. Lactated Ringer's solution 0.9% NaCl (normal saline) 5% dextrose in 0.9% NaCl 5% dextrose in water (D5W) 0.45% NaCl (½-strength normal saline) 10% dextrose in water (D10W)
0.9% NaCl (normal saline) Lactated Ringer's solution 5% dextrose in 0.9% NaCl Explanation: *dextrose = type of Glucose* *Lactated Ringer's solution = Electrolytes (calcium, sodium, cloride, potassium) along with water, balnaced between them its _isotonic_.* Basically, you need to give pt a balanced solution to offset the low volume. 0.9% NaCl (normal saline) and Lactated Ringer's solution are isotonic solutions that have a total osmolality close to that of the ECF and help replace the ECF in the treatment of hypovolemia. 5% dextrose in 0.9% NaCl is a hypertonic solution that can temporarily be used to treat hypovolemia if plasma expander is not available. *10% dextrose in water (D10W) is a hypertonic solution that is used in peripheral parenteral nutrition*. 0.45% NaCl (½-strength normal saline) is a hyptonic solution that provides Na+, Cl−, and free water and is used as a basic fluid for maintenance needs. 5% dextrose in water (D5W) is used in fluid loss, dehydration and hypernatremia, and should not be used in excessive volumes because it does not contain any sodium. Make sure it matches - if a patient's potassium level is noted to be elevated and the patient is prescribed a potassium-containing intravenous solution such as lactated Ringer's, the nurse should notify! Safety!
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? 3.5 cm H2O 12 cm H2O 9.5 cm H2O 5 cm H2O
3.5 cm H2O Explanation: The *normal pressure of ECF is approximately 4 to 11 cm H2O*. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.
What is blood plasma PH? Why is that? What PH is deadly?
Blood PH is: 7.4 (+/-.05) What there is too many released H+ free floating its Acidic. MANY H = ACID Alkaline is when too many H+ is trapped and becomes carbonic acid. LESS H = BASIC Deadly PH is eithere 6.80 to 7.80 (+/-.4)
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? -Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet. -ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. -Bowel motility will be restored within 24 hours after beginning supplemental K+. -ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+.
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Explanation: If the client is taking a *potassium-conserving diuretic*, he must be mindful of the amount of *potassium he is ingesting because the potassium level is more likely to elevate above normal*. *Cardiac dysrhythmias may result if hyperkalemia* occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Leave water on the bedside table. Offer small amounts of preferred beverage frequently. Ask the client every hour to drink more fluid. Have a loved one tell the client to drink more.
Offer small amounts of preferred beverage frequently. Explanation: 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. This intervention will assist in keeping oral mucosa moist and providing hydration needs.
Match _healthy Serum levels_ of major ions - Sodium (Na+), - Potassium (K+), - Calcium (Ca2+), - Magnesium (Mg2+), - Chloride (Cl−), - Bicarbonate (HCO3−), - Phosphate (PO4−) -mEq/L OR mg/dL? -1.8 -27 -140 -9.4 -3.5 -4.8 -102
Only two are mg/dL: PO4 (phosphate), and Ca (calcium). Remember: calcium and phosphate combine [Ca3(PO4)2] to give bones strength, and there is LOTS of bones in body! hence larger mass Largest to smallest: - Calcium (Ca2+) = 9.4 mg/dL - Phosphate (PO4−) = 3.5 mg/dL - Sodium (Na+) = 140 mEq/L - Chloride (Cl−) = 102 mEq/L - Bicarbonate (HCO3−) = 27 mEq/L - Potassium (K+) = 4.25 mEq/L - Magnesium (Mg2+) = 1.8 mEq/L ECF molecules will be bigger because ECF is more than the cells.
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: an infiltration. phlebitis. rapid fluid administration. a systemic blood infection.
Phlebitis = vein irretation Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, 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* (localized). 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 nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? Hands Sacral area Abdomen Face
Sacral area Explanation: *(dependent) Edema is present in lower parts of body* due to gravity. The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. Dependent edema is a term that doctors use to describe gravity-related swelling in the lower body. Gravity has the effect of pulling fluid down toward the earth, causing it too pool in the lowest parts of your body, such as your feet, legs, or hands. The edema cannot be assessed in the face, hands and abdomen, as these are not dependent areas.
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? -Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). -Sodium is regulated by the renin-angiotensin-aldosterone system. -If sodium is low, it means that there is not enough water. -Sodium is not regulated by natriuretic peptides.
Sodium is regulated by the renin-angiotensin-aldosterone system. Explanation: Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). *_Water usually follows sodium so if sodium is low, it means that there is too much water._* Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.
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 the brachial plexus vein. Use veins of the lower extremities. Use small veins before larger veins. Use distal veins before proximal veins.
Use distal veins before proximal veins. Explanation: Use larger veins and the distal portion of the vein, leaving the more proximal sites for later venipunctures (insertion).
Electrolytes in the ECF (ExtraCellular Fluid)? Mostly Electrolytes in the ICF (IntraCellular space)? mostly
_ECF_ = *Sodium*, chloride, calcium, and bicarbonate _ICF_ = *potassium*, phosphorus, and magnesium
Which client would be a candidate for total parenteral nutrition? a client receiving intravenous antibiotics a client with colitis and bloody diarrhea a postoperative appendectomy client a client with diabetic ketoacidosis
a client with colitis and bloody diarrhea Explanation: Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when *complete bowel rest is necessary for healing*. A client with bloody diarrhea and colitis requires complete bowel rest.
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? circulatory overload edema hypovolemia hypervolemia
hypovolemia Explanation: The nurse should recognize that *hypovolemia, also known as dehydration*, may be responsible. Dehydration causes strain on your heart. The amount of blood circulating through your body, or blood volume, decreases when you are dehydrated. *To compensate, your heart beats faster, increasing your heart rate and respirations and causing you to feel palpitations* Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; *warm skin*; furrowed tongue; low urine output; hardened stools; and *elevated: serum sodium,*hematocrit, hemoglobin, , and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.