Fluid, Electrolyte, and Acid-Base Balance (52) Flashcards
An older nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding?
- Increased blood pressure
- Weak, rapid pulse
- Moist mucous membranes
- Jugular vein distention
2. Weak, rapid pulse
All other options are indicative of fluid volume excess.
A client who has not eaten or drunk anything for several days would be experiencing fluid volume deficit.
A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?
- Start an IV.
- Review the results of serum electrolytes.
- Offer the woman foods that are high in sodium and potassium content.
- Administer an antiemetic.
2. Review the results of serum electrolytes.
Further assessment is needed to determine appropriate action.
While the nurse may perform some of the interventions in options 1, 3, and 4, assessment is needed initially.
The nurse administers an IV solution of D5 1/2NS to a postoperative client.
This is classified as what type of intravenous solution?
Hyertonic
An older client comes to the emergency department experiencing chest pain and shortness of breath. An arterial blood gas is ordered. Which of the following ABG results indicates respiratory acidosis?
- pH 7.54; PaCO2 28 mmHg; HCO3 22 mEq/L
- pH 7.32; PaCO2 46 mmHg; HCO3 24 mEq/L
- pH 7.31; PaCO2 35 mmHg; HCO3 20 mEq/L
- pH 7.50; PaCO2 37 mmHg; HCO3 28 mEq/L
- pH 7.32; PaCO2 46 mmHg; HCO3 24 mEq/L
Because of the retention of CO2, the clinical profile of respiratory acidosis includes decreased pH < 7.35, PaCO2 > 42 mmHg, with varying levels of HCO3 related to hypoventilation.
Option 1 is respiratory alkalosis, which occurs because of blowing off of CO2 resulting in a decreased level of acid and retention or produc- tion of bicarbonate, which in turn results in pH >7.45, PaCO2 < 38 mmHg, HCO3 > 26 mEq/L related to hyperventilation.
Option 3: Metabolic acidosis occurs because of a gain of hydrogen ions or a loss of HCO3 with a pH < 7.35, normal PaCO2 of 35–45 mmHg, and HCO3 < 22 mEq/L, often caused by diarrhea, bicarbonate infusion, or retention related to kidney failure.
Option 4: Metabolic alkalosis is caused by gain of bicarbonate or loss of hydrogen ions related to vomiting, gastric suction, or loss of upper gastrointestinal secretions by various other methods.
The intake and output (I&O) record of a client with a nasogastric tube who has been attached to suction for 2 days shows greater output than input. Which nursing diagnoses are most applicable? Select all that apply.
- Deficient Fluid Volume
- Risk for Deficient Fluid Volume
- Impaired Oral Mucous Membranes
- Impaired Gas Exchange
- Decreased Cardiac Output
1. Deficient Fluid Volume
3. Impaired Oral Mucous Membranes
5. Decreased Cardiac Output
Options 1, 3, and 5 relate to fluid volume deficit.
The data indicate an actual problem, which excludes option 2.
Option 4 relates more to fluid volume excess.
Which client statement indicates a need for further teaching regarding treatment for hypokalemia?
- “I will use avocado in my salads.”
- “I will be sure to check my heart rate before I take my digoxin.”
- “I will take my potassium in the morning after eating breakfast.”
- “I will stop using my salt substitute.”
4. “I will stop using my salt substitute.”
Salt substitutes contain potassium. The client can still use it within reason.
Option 1: Avocado is higher in potassium than most foods.
Option 2: Hypokalemia can potentiate digoxin toxicity and checking the pulse will help the client avoid this.
Option 3: It is important to take potassium with food to avoid gastric upset.
An older man is admitted to the medical unit with a diagnosis of dehydration. Which sign or symptom is most representative of a sodium imbalance?
- Hyperreflexia
- Mental confusion
- Irregular pulse
- Muscle weakness
2. Mental confusion
Sodium contributes to the function of neural tissue.
Because calcium contributes to the function of voluntary muscle contraction, options 1 and 4 are more appropriate for calcium imbalances.
Option 3: Because potassium and calcium contribute to cardiac function, irregular pulse is more likely to be associated with those alterations.
The client’s arterial blood gas results are:
pH 7.32; PaCO2 58; HCO3 32.
The nurse knows that the client is experiencing which acid–base imbalance?
- Metabolic acidosis
- Respiratory acidosis
- Metabolic alkalosis
- Respiratory alkalosis
2. Respiratory acidosis
Because of CO2 retention the PaCO2 is elevated. CO2 is involved in production of acid, which will result in a decreased pH. HCO3 will vary.
Option 1: Metabolic acidosis involves a loss of bicarbonate, but no retention of CO2.
Option 3: Metabolic alkalosis involves a loss of acid or retention of HCO3, but no retention of CO2.
Option 4: Respiratory alkalosis involves a loss of CO2 resulting in an increased pH.
A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority?
- Renal
- Cardiac
- Gastrointestinal
- Neuromuscular
4. Neuromuscular
The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity and not the renal, cardiac, or GI systems.
The nurse would assess for signs of hypomagnesemia in which of the following clients? Select all that apply.
- A client with renal failure
- A client with pancreatitis
- A client taking magnesium-containing antacids
- A client with excessive nasogastric drainage
- A client with chronic alcoholism
2. A client with pancreatitis
4. A client with excessive nasogastric drainage
5. A client with chronic alcoholism
Options 1 and 3 relate to hypermagnesemia.
