Taylor's Chapter 39: Fluid, Electrolyte, and Acid-Base balance (PrepU)

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

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 normal pressure is approximately 4 to 11 cm H2O.

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial Blood Gas

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?

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Supplemental potassium should not be added to the client's intake

A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded?

Fruit consumption

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, which may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?

Hypertonic Plasma is an isotonic solution.

Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease?

Increased plasma levels of antidiuretic hormone lead to water excess. In addition to increased plasma levels of antidiuretic hormones, plasma levels of albumin decrease, so that the distribution of extracellular fluid changes, vascular volume decreases, and interstitial volume increases. Complications often lead to ascites

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium?

Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L). Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently.

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. likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?

Sodium is regulated by the renin-angiotensin-aldosterone system.

The nurse is educating a client about the function of sodium in the body. What education points would the nurse make? Select all that apply.

Sodium is the primary regulator of ECF volume Sodium is normally maintained in the body within a relatively narrow range, and deviations quickly result in serious health problems. Sodium participates in the generation and transmission of nerve impulses.

A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse?

Spinach Sardines, whole grains, and green leafy vegetables also provide calcium.

A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply.

orthostatic hypotension decreased urine output slow-filling peripheral veins The signs and symptoms of decreased interstitial volume include dry mucous membranes and poor skin turgor.

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 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.

A decrease in arterial blood pressure will result in the release of:

renin.

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of the IV solution to a client. WHat is the standard drop factor of microdrip tubing?

60 drops/mL

Which client will have more adipose tissue and less fluid?

A woman

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 clients needs?

AN implanted central venous access device

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?

Acute Confusion related to cerebral edema

Rich source of potassium?

Apricots

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of:

Fluid volume excess

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?

Hyperphosphatemia Calcium and phosphorus have a reciprocal relationship

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?

In metabolic acidosis, arterial blood gas results are anticipated to reflect pH guch as 64; 42.

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?

Isotonic

When educating a client about foods that affect fluid balance, the nurse would advise the client to decrease:

Na+ Sodium (Na+) is the most abundant electrolyte in the extracellular fluid (ECF). Na+ regulates extracellular fluid volume; Na+ loss or gain is accompanied by a loss or gain of water. Potassium (K+) is the major intracellular electrolyte. Calcium (Ca++) is a major component of bones and teeth. Magnesium (Mg++) is the most abundant intracellular cation after potassium.

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

Platelets

A client is admitted to the intensive care unit with a calcium level of 4.2 mg/dL. What is the priority action by the nurse?

Prepare to administer calcium gluconate as prescribed

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion?

The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. A symptom of fluid overload is distended neck veins. Fluid overload is more likely in very young children. The infusion rate must be carefully monitored during the admin of blood.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

Which is a common anion?

Which is a common anion? Cl- Mg+, K+, and Ca+

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

A client with dehydration will have an increase in:

aldosterone

Potassium is needed for neural, muscle, and:

cardiac function.

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.

A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. THe nurse looks for a large vein when using a needle with a large guage. What explains the nurse's action?

To prevent cocmpromising circulation.

Which clients would be appropriate candidates for total parenteral nutrition? Select all that apply.

Client who has second- and third-degree (partial- or full-thickness) burns over 40% of the body Client who had gastric surgery and is unable to eat for a few weeks Client with anorexia nervosa

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find?

Hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia

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 that the client needs restoration of:

electrolytes. Non-electrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.

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

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

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate?

"Granulocytes are a type of white blood cell that can help fight infection."

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?

"I received a blood transfusion in the United Kingdom."

The nurse is calculating the infusion rate for the following order: Infuse 1000 ml of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtts/min. What is the infusion rate?

42 gtts/min When infusing by gravity, divide the total volume in ml (1000 ml) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtts/min

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O?

55-year old with congestive heart failure on furosemide clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy should be put on I&O

The nurse is calculating an infusion rate for the following order: Infuse 1000 ml of 0.9% Na Cl over 12 hours using an electronic infusion device. What is the infusion rate?

83 ml/hour When calculating the infusion rate with an electronic device, divide the total volume to be infused (1000 ml) by the total amount of time in hours (12). This is 83 ml/hour

Which age group is at risk for fluid and electrolyte imbalances resulting from fad dieting?

Adolescents

The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?

Cardiac volume intolerance

Verification for blood transfusion?

Clients name ID number Unit number ABO group

The nurse reviews the laboratory 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 gastrointestinal system?

Diarrhea Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia.

The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply.

Diarrhea Cardiac dysrhythmia

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 Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.

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 distal veins before proximal veins leaving the more proximal sites for later venipunctures.

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

calcium and phosphorus

A client has been admitted with fluid volume excess related to left sided heart failure. Which assessment data would the nurse document related to the fluid volume excess? (Select all that apply.)

crackles in the lungs distended neck veins and DECREASED URINE OUTPUT

The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply.

facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes

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.

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 spasms) hypercalcemia = nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. hyperchloremia = diminished cognitive ability and hypertension Constipation is a sign of hypercalcemia.

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.

respiratory muscle weakness confusion ventricular dysrhythmia

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? (Select all that apply.)

respiratory muscle weakness confusion ventricular dysrhythmia Fluid volume deficit causes a low BP (100/48 mm Hg), poor skin turgor, and an elevated heart rate (128/bpm). Fluid excess can cause crackles and distended neck veins.

A client who is receiving total parenteral nutrition and lipids asks the nurse why the solution looks like milk. What is the most appropriate nursing response?

"The white milky solution contains lipids or fat to provide extra calories." A parenteral lipid emulsion is a mixture of water and fats in the form of soybean or safflower oil, egg yolk phospholipids, and glycerin. Lipid solutions, which look milky white, are given intermittently with TPN solutions. They provide additional calories and promote adequate blood levels of fatty acids. Lipids cannot be mixed with TPN, as the lipid molecules tend to break or separate

A nursing instructor is discussing administration of total parenteral nutrition (TPN) with a nursing student. Which statement by the student would require further teaching?

"I will be sure to change the TPN tubing every other day."

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've been taking antacids almost every 2 hours over the past several days." Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit. V or nasogastric suction diarrhea = metabolic acidosis

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 nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply.

"The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." The adrenal glands regulate blood volume by secreting aldosterone." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." The heart and blood vessels react to hypovolemia by stimulating fluid retention rather than the kidneys.

The passageways of the kidney permit the urine to flow to the bladder and:

selectively reabsorb or secrete substance to maintain fluids and electrolytes.

The student nurse asks the instructor how buffer systems work in the body to maintain the pH of the blood. The instructor explains each of the buffer systems to the students. Which are buffer systems that will be discussed by the instructor?

Carbonic acid-sodium bicarbonate buffer system. Phosphate buffer system. Protein buffer system.