Chapter 13: Fluid and Electrolytes Flashcards
(105 cards)
0
Q
Patients diagnosed with hypervolemia should avoid sweet or dry food because
A
It increases the patient’s desire to consume fluid
1
Q
Which of the following are the insensible mechanisms of fluid loss?
A
Breathing
2
Q
Air embolism is a potential complication of IV therapy. The nurse should alert to which clinical manifestation associated with air embolism?
A
Chest pain
3
Q
Below which sodium level may convulsions or coma can occur?
A
135 mEq/L
4
Q
Which of the following electrolytes is a major cation in body fluid?
A
Potassion
5
Q
Oncotic pressure refers to the
A
Osmotic pressure exerted by proteins
6
Q
Which of the following is the most common cause of symptomatic hypomagnesemia?
A
Alcoholism
7
Q
Which nerve is implicated in the Chvostek’s sign?
A
Facial
8
Q
Oral intake is controlled by the thirst center, located in which of the following cerebral areas?
A
Hypothalamus
9
Q
A client hospitalized for treatment of pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
A
Light-headedness or paresthesia
10
Q
A 57 y.o. homeless female with a history of alcohol abuse has been admitted to your hospital unit with signs and symptoms of hypovolemia—minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?
A
Third-spacing
11
Q
A 64- y.o. client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for the client?
A
No, sodium intake should be restricted
12
Q
The calcium level of blood is regulated by which mechanism?
A
Parathyroid hormone (PTH)
13
Q
To confirm an acid-base imbalance, it is necessary to assess which of the following findings from the results of a client’s arterial blood gas (ABG) results? Select all that apply.
A
HCO3, PaCO2, pH
14
Q
Translocation is a term used to describe the general movement of fluid and chemicals within body fluids. In every client’s body, fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?
A
Osmosis
15
Q
A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.
A
Drink water as an inexpensive way to meet fluid needs
Respond to thirst
Drink at least eight glasses of fluid each day
16
Q
A pt is being treated in the ICU 24 hrs after having a radical neck dissection completed. The pt’s serum calcium level is 7.6 mg/dL. Which of the following physical examination findings is consistent with this electrolyte imbalance?
A
Pressence of Trousseau’s sign
17
Q
A 42 y.o. client has chronic hyponatremia, which requires weekly blood labs to keep him from lapsing into convulsions or a coma. What is the level of serum sodium below which convulsions or coma can occur?
A
135 mEq/L
18
Q
An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?
A
Hypokalemia
19
Q
A 64 yo client is brought into the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, and rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for the client?
A
No, sodium intake should be restricted.
20
Q
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?
A
Metabolic Acidosis
21
Q
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His ABG analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?
A
Metabolic alkalosis
22
Q
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?
A
Tachycardia
- Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid.
Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.
23
Q
Which of the following solutions is hypotonic?
A
0.45% NaCl - Half-strength saline is hypotonic.
Lactated Ringer’s solution is isotonic.
Normal saline (0.9% NaCl) is isotonic.
A solution that is 5% NaCl is hypertonic.
24
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?
Respiratory alkalosis
- A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.
25
A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unit. She was admitted with signs and symptoms of hypovolemia - minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?
3rd Spacing
- Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites.
26
Which of the following arterial blood gas results would be consistent with metabolic alkalosis?
Serum bicarbonate of 28 mEq/L
- Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
27
A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond?
Bicarbonate-carbonic acid buffer system
- The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system.
28
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?
Lactated Ringer's solution
- Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.
29
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
Light-headedness or paresthesia
- The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
30
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?
Instruct the client to breathe into a paper bag.
- The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.
31
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?
Respiratory alkalosis
- Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.
32
Oral intake is controlled by the thirst center, located in which of the following cerebral areas?
Hypothalamus
33
Below which serum sodium level may convulsions or coma can occur?
135 mEq/L
- Normal serum concentration level ranges from 135 to 145 mEq/L. When the level dips below 135 mEq/L, there is hyponatremia. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L are within the normal range.
34
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?
pH 7.48
- Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.
35
You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults?
Dehydration
- The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances.
36
Which of the following electrolytes is a major cation in body fluid?
Potassium
- Potassium is a major cation that affects cardiac muscle functioning. Chloride is an anion. Bicarbonate is an anion. Phosphate is an anion.
37
The calcium level of the blood is regulated by which mechanism?
Parathyroid hormone (PTH)
- The serum calcium level is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium level in the blood.
38
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?
Sodium
- Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.
39
Which of the following is a correct route of administration for potassium?
Oral
- Potassium may be administered through the oral route. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. Potassium is not administered subcutaneously.
40
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?
Urine pH of 3.0
- Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.
41
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?
Acidic
- Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
42
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?
The client had a liver transplant 2 years ago.
- A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.
43
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her:
electrocardiogram (ECG) results.
- Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
44
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?
Metabolic Acidosis
- This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.
45
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
- Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.
46
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:
Respiratory alkalosis
- This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.
47
A priority nursing intervention for a client with hypervolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications.
- Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.
48
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
pH, 7.25; PaCO2 50 mm Hg
- In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.
49
An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?
Hypokalemia
- Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a defict in total potassium stores. Potassium-losing diuretics, such as loop diuretics, can induce hypokalemia.
50
In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply.
• Heart failure
• Pulmonary edema
• Renal impairment
- Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries.
51
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?
Arterial blood gas (ABG) analysis
- Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.
52
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance?
Hypercalcemia
- The normal reference range for serum calcium is 9 to 11 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.
53
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?
Metabolic Alkalosis
- A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.
54
Which of the following arterial blood gas results would be consistent with metabolic alkalosis?
Serum bicarbonate of 28 mEq/L
- Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
55
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?
Confusion and seizures
- Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.
56
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?
Respiratory alkalosis
- Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.
57
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
Extreme Anxiety
- Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.
58
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?
Chest Pain
- Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.
59
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?
Tachycardia
- Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.
60
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?
Arterial blood gas (ABG) analysis
- Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.
61
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?
Respiratory Alkalosis
- A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.
62
The nursing student asks their instructor what the term is for the amount of hydrogen ions in a solution. What should the instructor respond?
pH
- The symbol pH refers to the amount of hydrogen ions in a solution; pH can range from 1, which is highly acidic, to 14, which is highly basic. All other options are incorrect.
63
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
- Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.
64
You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema?
Generalized
- There may be generalized edema in all the interstitial spaces, which sometimes is called brawny edema or anasarca.
65
You are making rounds on your clients. You find one of your clients struggling to breathe, appears confused, has tachycardia, and the skin appears dusky. What should you do to restore normal pH if ventilation efforts are not very successful?
Administer Sodium Bicarbonate IV
- When the client makes frantic efforts to breathe, breathes slowly, or stops breathing, and has tachycardia, and the skin appears dusky (cyanosis), the condition is likely to be acute respiratory acidosis. The accumulation of CO2 leads to behavioral changes, including confusion. Excess carbonic acid pulls pH below 7.35. The nurse should administer sodium bicarbonate IV to balance the acid and bring the pH to a normal level. Bronchodilators may be useful in chronic respiratory acidosis but not in the acute version. Potassium (needed in hypokalemia) and magnesium sulfate (needed in hypomagnesemia) have no role in acute respiratory acidosis
66
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:
Respiratory Alkalosis
- This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.
67
The human body is an intricate mechanism which maintains homeostasis through a multitude of chemical reactions. The measureable chemical levels disclose how well the body is (or is not) functioning. Which of these chemical substances release hydrogen into fluid?
Acids
- Acids are substances that release hydrogen into fluid. The delicate balance of fluid, electrolytes, acids, and bases is ensured by an adequate intake of water and nutrients, physiologic mechanisms that regulate fluid volume, and chemical processes that buffer the blood to keep its pH nearly neutral.
68
Early signs of hypervolemia include
Increased breathing effort and weight gain
- Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. An earliest symptom of hypovolemia is thirst
69
The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?
Bicarbonate
- Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.
70
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?
Jugular Vein Distension
- Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.
71
As Americans live longer, relatively rare conditions are becoming more commonplace - one of which is hypervolemia. What are early signs of hypervolemia? Choose all correct options.
Weight Gain & Increased breathing effort
- Early signs of hypervolemia are elevated BP, increased breathing effort, etc. Eventually, fluid congestion in the lungs leads to moist breath sounds. An earliest symptom of hypovolemia is thirst.
72
Which of the following arterial blood gas results would be consistent with metabolic alkalosis?
Serum bicarbonate of 28 mEq/L
- Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
73
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?
Acidic
- Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
74
A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows:
Na + 147 mEq/L
K + 3.0 mEq/L
Cl - 112 mEq/L
Mg ++ 2.3 mg/dL
Ca ++ 1.5 mg/dL
Which of the following is consistent with the client's findings?
Hypokalemia
- Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a d...(more)
Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias.
75
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?
Extracellular Fluid Volume Deficit
- Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreaesd fluid intake. A cause of this loss is hemorrhage.
76
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:
Muscle Weakness
- Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.
77
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?
Increased arterial pH
- Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.
78
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
Serum sodium level of 124 mEq/L
- In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.
79
Which of the following is a factor affecting an increase in serum osmolality?
Free Water Loss
- Free water loss is a factor increasing serum osmolality. Diuretic use, overhydration, and hyponatremia are factors decreasing serum osmolality.
80
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values.
Na + 130 mEq/L
K + 4.6 mEq/L
Cl - 94 mEq/L
Mg ++ 2.8 mg/dL
Ca ++ 13 mg/dL
Which of the following alterations is consistent with the client's findings?
Hypercalcemia
- More than 99% of the body's calcium is found in the skeletal system. Hypercalcemia (greater than 10.2 mg/dL) can be a dangerous imbalance. The client presents with anorexia, nausea and vomiting, constipation, abdominal pain, bone pain, and confusion.
81
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
Extreme Anxiety
- Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.
82
Which of the following is a factor affecting an increase in urine osmolality?
Syndrome of inappropriate antidiuretic hormone release (SIADH)
- Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and congestive heart failure. Myocardial infarction typically is not a factor that increases urine osmolality.
83
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?
Pulse
- An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client's pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing respirations and temperature because these aren't affected by the serum potassium level.
84
In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply.
• Severe hemorrhage
• Pulmonary edema
• Heart failure
• Burns
• Renal Impairment
Heart Failure, Pulmonary Edema, Renal Impairment
- Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries.
85
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?
Metabolic Alkalosis
- Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma biacarbonate concentration. The most common cuase of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.
86
A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?
Shock
- Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren't associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.
87
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?
Cerebral Edema
- Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.
88
A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values:
Na+ 134 mEq/L
K+ 3.2 mEq/L
Cl- 111 mEq/L
Mg++ 1.1 mg/dL
Ca++ 8.4 mg/dL
Identify which of the following alterations is consistent with the client's findings.
Hypomagnesemia
- Magnesium, the second most abundant intracellular cation, plays a role in both carbohydrate and protein metabolism. The most common cause of this imbalance is loss in the gastrointestinal tract. Hypomagnesemia is a value less than 1.3 mg/dL. Signs and symptoms include muscle weakness, tremors, irregular movements, tetany, vertigo, focal seizures, and positive Chvostek's and Trousseau's signs.
89
Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?
Hypomagnesemia
- If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.
90
A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?
Respiratory Acidosis
- Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.
91
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:
Muscle weakness
- Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.
92
A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows:
Na + 147 mEq/L
K + 3.0 mEq/L
Cl - 112 mEq/L
Mg ++ 2.3 mg/dL
Ca ++ 1.5 mg/dL
Which of the following is consistent with the client's findings?
Hypokalemia
- Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias.
93
You are caring for a client that has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition?
Hypocalcemia
- Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia
94
A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?
Hyperkalemia
- Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination doesn't help reverse the effects of hypercalcemia, hypernatremia, or hyperglycemia.
95
A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply.
• Reddended area along the path of the vein
• Tender area around the insertion site
• Ecchymosis at the insertion site
• Rapid, shallow respirations
• Cool area around the insertion site
Reddended area along the path of the vein & Tender area around the insertion site
-Phlebitis is inflammation of a vein and is characterized by a reddened, warm area around an insertion site or along the path of a vein. The involved area is also tender and swollen. The nurse assesses infusion sites and determines the proper action to take. If indications lead to suspected phlebitis, the nurse will discontinue the intravenous line and restart with a different vessel.
96
Your client's lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?
Metabolic Acidsosis
- The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) minus (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis
97
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply.
Clinical manifestations of FVE include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.
98
Which of the following is a factor that increases blood urea nitrogen (BUN)?
GI Bleeding - Factors that increase BUN include GI bleeding, dehydration, increased protein intake, and fever.
99
The Emergency Department (ED) nurse is caring for a client who is known to make excessive use of laxatives who is showing signs of bradycardia. The client is admitted for hemodialysis. The ED nurse knows that a major goal of managing this client is what?
Flush out Excess magnesium
- The main objective is to flush out excess magnesium. Laxatives contain magnesium, and their excessive use may cause hypermagnesemia. Bradycardia or slow heart rate is one of the signs of this imbalance. In severe cases, hemodialysis may be necessary. Magnesium sulfate is administered in hypomagnesemia and not hypermagnesemia. Mechanical ventilation is necessary only if there is a change in respiratory rate, rhythm, or depth. The physician may permit the use of magnesium-free laxatives and the client should follow the recommended frequency of their use.
100
A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
Hyperkalemia
- Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. Administering glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.
101
Which of the following may occur with respiratory acidosis?
Increased Intracranial Pressure (ICP)
- If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.
102
A fluid volume deficit can be caused by either dehydration or hypovolemia. What is the distinction between the two?
a) In hypovolemia all fluid compartments have decreased volumes.
b) In dehydration intracellular fluid volume is depleted.
c) In hypovolemia only blood volume is low.
d) In dehydration only blood volume is low.
In hypovolemia only blood volume is low
- Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. This makes options A, B, and D incorrect.
103
Which of the following is a function of calcitonin? Select all that apply.
Reduces bone resorption, Increases urinary excretion of calcium, Increases deposition of calcium in bones
- Calcitonin reduces bones resorption, increasing deposition of calcium and phosphorous in the bones, and increases urinary excretion of calcium and phosphate.
104
You notify the physician that your client is third-spacing fluid. What orders would you expect the physician to give you?
Start IV fluids and blood products
- This is done by administering IV solutions—sometimes at rapid rates—and blood products, such as albumin, to restore colloidal osmotic pressure. The restriction of fluids; the administration of diuretics and the increase of sodium in the diet are not orders the physician would be expected to give for a client is third-spacing fluids.
