Taylor Chap. 40 Fluid, Electrolyte, and Acid-base balance

1. The principal extracellular electrolytes are? 2. The dominant extracellular cation is?

1. Sodium, calcium, and bicarbonate. 2. Sodium (Na+).

1. The principal intracellular electrolytes are? 2. The dominant intracellular cation is?

1. potassium, magnesium, and phosphorus 2. Potassium (K+)

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2500 mL/day

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

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."

The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

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

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy?

Administering the IV solution. Deciding the size of the IV catheter. Deciding the location of the IV catheter

Negatively charged ions are called?

Anions

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?

Apricots

An accumulation of serous fluid in the peritoneal cavity

Ascites

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.

This hormone is secreted by the thyroid to oppose PTH and reduce calcium levels in the body.

Calcitonin

______________ is essential for: Neuromuscular function Transmission of nerve impulses Blood clotting Formation of bones and teeth

Calcium

An essential cation that is widely distributed, found in bone, teeth, blood, and muscles. Normal serum range = 8.5-10.5 mg/dL

Calcium (Ca++)

Positively charged ions are called?

Cations

The major anion of extracellular fluid (ECF). Normal serum range = 95-105 mEq/L. Maintains acid-base balance, osmotic pressure, and acidity of gastric secretions.

Chloride (Cl-)

When magnesium levels increase, calcium levels __________.

Decrease

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action?

Discontinue IV

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another site.

Causes of ____________ include ingesting large amounts of salt without water, drinking salt water, rapid infusion of hypertonic/isotonic saline, or excess water loss from diarrhea, decreased fluid intake, diabetes insipidus.

Hypernatremia

Tetany, low BP, and shortening of the QT interval may occur with?

Hyperphosphatemia

Clinical manifestations of _______________ include tachypnea, distended neck veins, and edema.

Hypervolemia

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

Hypokalemia

Decreased preload and decreased cardiac output are signs of what life-threatening condition?

Hypovolemic shock

A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot?

Infant

The ______________ are the main regulators of sodium levels in the body. Aldosterone and ADH play major roles in regulating sodium.

Kidneys

A major intracellular cation found in soft tissue, muscle, and bone and is essential for protein and DNA synthesis. Normal serum range = 1.5-2.5 mg/dL

Magnesium

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

The measure of the number of particles dissolved in solution.

Osmolality

This hormone regulates the absorption and excretion of calcium, increasing levels by causing a release of calcium from bones.

Parathyroid Hormone (PTH)

A nurse is caring for a client who is not able to take food orally for 1 week to 10 days. Which type of nutrition is the client likely receive?

Peripheral parenteral nutrition

A major intracellular anion. Normal serum range = 2.5-4.5 mg/dL

Phosphorus

Increased fluid in the pleural space; can cause SOB by compression of the lung and/or intrathoracic pressure resulting in mediastinal shift

Pleural Effusion

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

Potassium

The major cation within the body's cells (intracellular). Normal serum range is 3.5/5 mEq/L

Potassium (K+)

When considering client safety, what is the primary purpose of the action demonstrated by the nurse involved in preparing for the administration of a prescribed IV solution?

Preventing embolus

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

The major cation of extracellular fluid often combines with chloride and has a normal serum level of 135-145 mEq/L.

Sodium (Na+)

In this syndrome high levels of ADH excreted by the posterior pituitary gland cause the body to retain water and certain levels of electrolytes in the blood to fall (ie. Sodium)

Syndrome of Inappropriate Anti-diuretic Hormone (SIADH)

Clinical manifestations of hypovolemia include:

Tachycardia and hypotension

Sometimes extracellular fluid becomes trapped in space where it is unable to be utilized or excreted which is called?

Third-spacing

The two most important assessments for evaluating fluid balance are?

an accurate I & O and daily weight

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

Causes of _____________ include excessive diuresis, excess sweating, GI fluid loss (vomting, diarrhea), adrenocorticoid insufficiency, or excess water due to excessive IV administration or excess oral fluid intake.

hyponatremia

Arterial blood gases 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

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parenteral nutrition.