chapter 42 : fluid, electrolyte, acid-based balance Flashcards
A patient is experiencing dehydration. While planning care, the nurse considers that the majority of the patient’s total water volume exists in with compartment?
a. Intracellular
b. Extracellular
c. Intravascular
d. Transcellular
a. Intracellular
Intracellular (inside the cells) fluid accounts for approximately two thirds of total body water. Extracellular (outside the cells) is approximately one third of the total body water. Intravascular fluid (liquid portion of the blood) and transcellular fluid are two major divisions of the extracellular compartment.
The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing?
a. Osmosis
b. Filtration
c. Diffusion
d. Active transport
a. Osmosis
The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Diffusion is passive movement of electrolytes or other particles down the concentration gradient (from areas of higher concentration to areas of lower concentration). Active transport requires energy in the form of adenosine triphosphate (ATP) to move electrolytes across cell membranes against the concentration gradient (from areas of lower concentration to areas of higher concentration).
The nurse observes edema in a patient who is experiencing venous congestion as a result of right heart failure. Which type of pressure facilitated the formation of the patient’s edema?
a. Osmotic
b. Oncotic
c. Hydrostatic
d. Concentration
c. Hydrostatic
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, such as inflammation or malnutrition. Concentration pressure is not a nursing term.
The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift to occur in what direction?
a. From intracellular to extracellular
b. From extracellular to intracellular
c. From intravascular to intracellular
d. From intravascular to interstitial
a. From intracellular to extracellular
Hypertonic solutions will move fluid from the intracellular to the extracellular (intravascular). A hypertonic solution has a concentration greater than normal body fluids, so water will shift out of cells because of the osmotic pull of the extra particles. Movement of water from the extracellular (intravascular) into cells (intracellular) occurs when hypotonic fluids are administered. Distribution of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.
A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one?
1.Clean site
2. Select vein
3. Apply tourniquet
4. Release tourniquet
5. Reapply tourniquet
6. Advance and secure
7. Insert vascular access device
a. 1, 3, 2, 7, 5, 4, 6
b. 1, 3, 2, 5, 7, 6, 4
c. 3, 2, 1, 5, 7, 6, 4
d. 3, 2, 4, 1, 5, 7, 6
d. 3, 2, 4, 1, 5, 7, 6
The steps for inserting an intravenous catheter are as follows: Apply tourniquet, select vein, release tourniquet, clean site, reapply tourniquet, insert vascular access device, and advance and secure.
The nurse is laboratory blood results will expect to observe which cation in the most abundance?
a. Sodium
b. Chloride
c. Potassium
d. Magnesium
a. Sodium
Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation. Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium 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 15.5 mg/dL
c. Potassium of 3.5 mEq/L
d. Chloride of 100 mEq/L
b. Calcium of 15.5 mg/dL
Normal calcium range is 9 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145 mEq/L, potassium 3.5 to 5.0 mEq/L, and chloride 98 to 106 mEq/L.
The nurse observes that the patient’s calcium is elevated. When checking the phosphate level, what does the nurse expect to see?
a. An increase
b. A decrease
c. Equal to calcium
d. No change in phosphate
b. A decrease
Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease.
Four patients arrive at the emergency department at the same time. Which patient will the nurse see first?
a. An infant with temperature of 102.2F and diarrhea for 3 days
b. A teenager with a sprained ankle and excessive edema
c. A middle-aged adult with abdominal pain who is moaning and holding her stomach
d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60
a. An infant with temperature of 102.2F and diarrhea for 3 days
The infant should be seen first. An infant’s proportion of total body water (70% to 80% total body weight) is greater than that of children or adults. Infants and young children have greater water needs and immature kidneys. They are at greater risk for extracellular volume deficit and hypernatremia because body water loss is proportionately greater per kilogram of weight. A teenager with excessive edema from a sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older adult with a blood pressure of 112/60.
The patient has an intravenous(IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one?
1.Remove the sleeve of the gown from the arm without the IV 2.Remove the sleeve of the gown from the arm with the IV 3.Remove the IV solution container from its stand
4.Pass the IV bag and tubing through the sleeve
a. 1, 2, 3, 4
b. 2, 3, 4, 1
c. 3, 4, 1, 2
d. 4, 1, 2, 3
a. 1, 2, 3, 4
Change regular gowns by following these steps for maximum speed and arm mobility: (1) To remove a gown, remove the sleeve of the gown from the arm without the IV line, maintaining the patient’s privacy. (2) Remove the sleeve of the gown from the arm with the IV line. (3) Remove the IV solution container from its stand and pass it and the tubing through the sleeve. (If this involves removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental infusion of a large volume of solution or medication.)
A 2-year-old child has ingested a quantity of a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
b. Respiratory acidosis
Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, 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.
A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?
a. Respiratory alkalosis
b. Metabolic alkalosis
c. Metabolic acidosis
d. Respiratory acidosis
b. Metabolic alkalosis
The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much acid is in the body like kidney failure.
Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?
a. pH 7.60, PaCO240 mm Hg, HCO3–30 mEq/L
b. pH 7.53, PaCO230 mm Hg, HCO3–24 mEq/L
c. pH 7.35, PaCO235 mm Hg, HCO3–26 mEq/L
d. pH 7.25, PaCO248 mm Hg, HCO3–23 mEq/L
b. pH 7.53, PaCO230 mm Hg, HCO3–24 mEq/L
Respiratory alkalosis should show an alkalotic pH and decreased CO2(respiratory) values, with a normal HCO3–. In this case, pH 7.53 is alkaline (normal = 7.35 to 7.45), PaCO2is 30 (normal 35 to 45 mm Hg), and HCO3–is 24 (normal = 22 to 26 mEq/L). A result of pH 7.60, PaCO240 mm Hg, HCO3–30 mEq/L is metabolic alkalosis. pH 7.35, PaCO235 mm Hg, HCO3–26 mEq/L is within normal limits. pH 7.25, PaCO248 mm Hg, HCO3–23 mEq/L is respiratory acidosis.
A nurse is caring for a patient whose electrocardiogram (ECG) presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect?
a. Dry mucous membranes
b. Abdominal distention
c. Distended neck veins
d. Flushed skin
b. Abdominal distention
Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia.
In which patient will the nurse expect to see a positive Chvostek’s 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 broken hip related to osteoporosis
b. A 24-year-old adult admitted for chronic alcohol abuse
A positive Chvostek’s sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia 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 experience extracellular fluid volume deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia.
A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient?
a. Renal
b. Endocrine
c. Respiratory
d. Gastrointestinal
a. Renal
The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance.
A nurse is caring for a patient prescribed peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel?
a. Recording intake and output
b. Regulating intravenous flow rate
c. Starting peripheral intravenous therapy
d. Changing a peripheral intravenous dressing
a. Recording intake and output
A nursing assistive personnel (AP) can record intake and output. An RN cannot delegate regulating flow rate, starting an IV, or changing an IV dressing to an NAP.
The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis?
a. pH 7.3, PaCO236 mm Hg, HCO3–19 mEq/L
b. pH 7.5, PaCO235 mm Hg, HCO3–35 mEq/L
c. pH 7.32, PaCO247 mm Hg, HCO3–23 mEq/L
d. pH 7.35, PaCO240 mm Hg, HCO3–25 mEq/L
a. pH 7.3, PaCO236 mm Hg, HCO3–19 mEq/L
The laboratory values that reflect metabolic acidosis are pH 7.3, PaCO236 mm Hg, HCO3–19 mEq/L. A laboratory finding of pH 7.5, PaCO235 mm Hg, HCO3–35 mEq/L is metabolic alkalosis. pH 7.32, PaCO247 mm Hg, HCO3–23 mEq/L is respiratory acidosis. pH 7.35, PaCO240 mm Hg, HCO3–25 mEq/L values are within normal range.
