Chapter 41: Fluid, Electrolyte, and Acid-Base Balance MeaganNicole Quizlet Flashcards
A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother's purse. The nurse knows that the child is at greatest risk for which acid- base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
ANS: A Morphine overdose can cause respiratory depression and hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hy- perventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.
Approximately two thirds of the body's total water volume exists in the \_\_\_\_\_ fluid. a. Intracellular b. Interstitial c. Intravascular d. Transcellular
ANS: A Intracellular fluid accounts for approximately two thirds of the fluids in the body—about 42% of total body weight. Interstitial fluid, intravascular fluid, and transcellular fluid constitute extra-cellular fluid, which is the fluid outside a cell.
A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. "Are you having difficulty sleeping at night?" b. "How many calories a day do you con-sume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"
ANS: D A rapid gain in weight usually indicates ECV excess if the person began with normal ECV. Asking the patient about urination habits will illuminate whether the body is trying to excrete the excess fluid, or if renal dysfunction is contributing to ECV excess. Difficulty sleeping at night can occur if the body builds up excessive fluid in the lungs; however, it could also mean that the patient is getting up frequently to urinate, so the question is not specific enough. Caloric intake does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.
In which patient would the nurse expect to see a positive Chvostek sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a bro-ken hip related to osteoporosis
ANS: B A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomag- nesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which also can be affected by alcohol consumption). Burn patients frequently expe-rience ECV deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia.
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 20 mL/hr. At what time should the infusion be completed? a. 0645 Tuesday b. 0675 Tuesday c. 0715 Tuesday d. 0735 Tuesday
ANS: C 250 mL divided by 20 mL/hr = 12.5 hr 0.5 hr 60 min = 30 min 1845 + 12 hr 30 min = 3115, which would be 0715 on Tuesday, the following day.
The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most concerned about? a. Potassium imbalance b. Sodium imbalance c. Calcium imbalance d. Phosphate imbalance
ANS: A Using a diuretic can cause excess excretion of potassium, unless it is a potassium-sparing diuretic. The other electrolytes are not excreted in the same way with diuretics.
A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. The nurse recognizes that the patient is experiencing which transfusion complication? a. Anaphylactic shock b. Septicemia c. Fluid volume overload d. Hemolytic reaction
ANS: C The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.
A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, elevated white blood cell count, and oral candidiasis. The nurse knows that the purpose of starting total parenteral nutrition (TPN) is to a. Replace fluid, electrolytes, and nutrients in the patient. b. Stimulate the patient's appetite to eat. c. Provide medication to raise the patient's blood pressure. d. Deliver antibiotics to fight off infection.
ANS: A Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace the ones the patient is not eating. TPN does not stimulate the appetite. TPN does not contain blood pressure medication or antibiotics.
The nurse is caring for a diabetic patient in renal failure. Which laboratory findings would the nurse expect? a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L c. pH 7.3, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L
ANS: A Patients in renal failure develop metabolic acidosis. The laboratory values that reflect this are pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L is metabolic alkalosis. pH 7.3, PaCO2 47 mm Hg, HCO3- 23 mEq/L is respira-tory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L values are within normal range.
A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 4 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300 mL output. The patient has voided 400 mL of urine. After reporting these values to the physician, what orders does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Discontinue the nasogastric suctioning. d. Administer a diuretic to prevent fluid volume excess.
ANS: A The total fluid intake and output equals 700 mL, which meets the provider goals. Record half the volume of ice chips when calculating intake. Patients with nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition. The other measures would be unnecessary because the net fluid volume is equal.
A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patient's peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Notify the physician. b. Administer pain medication. c. Discontinue the IV. d. Start a new IV line.
ANS: D The IV site has phlebitis. The nurse should start a new IV before discontinuing the old one be-cause it is important to always have an IV access site in a patient who is in hypertensive crisis. Then the physician can be notified. Pain medication may or may not need to be administered
A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding would the nurse expect? a. Thready peripheral pulses b. Abdominal distention c. Dry mucous membranes d. Flushed skin
ANS: B Signs and symptoms of hypokalemia are muscle weakness and fatigue, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hyper- natremia.
The nurse is caring for a patient with hyperkalemia. Which body system would be most important for the nurse plan to monitor closely? a. Gastrointestinal b. Neurological c. Cardiac d. Respiratory
ANS: C Potassium balance is necessary for cardiac function. Hyperkalemia places the patient at risk for potentially serious dysrhythmias. Monitoring of gastrointestinal, neurological, and respiratory systems would be indicated for other electrolyte imbalances.
The nurse is caring for a patient with sepsis. The plan of care for the patient is to administer antibiotics 3 times a day for 4 weeks. What device will be used to administer these antibiotics? a. A continuous infusion b. A heparin locked peripheral catheter c. A PICC line d. An implanted port catheter
A PICC line is a type of central venous device that can be introduced into a peripheral vein for administration of IV
antibiotics for an extended period, over the course of several weeks. A continuous infusion would not take place if
the patient received antibiotics only 3 times daily. A pe-ripheral catheter would not be necessary or heparin locked. An implanted port catheter is in-tended for long-term use of venous access over months, or even years.
A nurse is preparing to administer a blood transfusion. Which assessment finding would the nurse report immediately? a. Blood pressure 120/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats per minute
ANS: B A fever should be reported immediately, and the blood transfusion may be postponed. All other assessment findings are acceptable before starting a blood transfusion.
The nurse knows that an imbalance of which ion causes acid-base impairment? a. Hydrogen b. Calcium c. Magnesium d. Sodium
ANS: A The concentration of hydrogen ions determines pH. Low pH designates an acidic environment. High pH designates an alkaline environment. Calcium, magnesium, and sodium are ions, but their imbalances are not direct acid-base impairments.
The nurse knows that edema in a patient who has venous congestion from right heart failure is facilitated by an imbalance with regard to \_\_\_\_\_ pressure. a. Hydrostatic b. Osmotic c. Oncotic d. Concentration
ANS: A Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes and can contribute to edema in other situations. Concentration pressure is not a nursing term.
The nurse knows that intravenous fluid therapy has been effective for a patient with hypernatremia when a. Serum sodium concentration returns to normal. b. Systolic and diastolic blood pressure decrease. c. Large amounts of emesis and diarrhea decrease. d. Urine output increases to 150 mL/hr.
ANS: A Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia.
The nurse knows that the most abundant cation in the blood is a. Sodium. b. Potassium. c. Chloride. d. Magnesium.
ANS: A Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cat-ion. Chloride is an anion (negatively charged) rather then a cation (positively charged). Magne-sium is found predominantly inside cells and in bone.
The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 17.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L
ANS: B Normal calcium range is 8.5 mg/dL to 10.5 mg/dL; therefore, a value of 17.5 mg/dL is abnor-mally high and of concern. The rest of the laboratory values are within their normal ranges: so-dium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; chloride 98 to 106 mEq/L.