whitney_flansburg Preview

Fluid/Electrolytes and Acid-Base Balance & ABG's Nclex ScienceMedicineNursing christybox Save ATI Fluid, Electrolyte, and Acid-Bas...30 terms whitney_flansburg Preview

Chapter 17: Fluid, Electrolyte, and A...

30 terms PRISCILLA_PETERS... Preview

Lewis Chapter 17: Fluid, Electrolyte, ...

32 terms CRNADNPPreview Fluid a 33 terms Ale A patient with an acid-base imbalance has an altered potassium level. The nurse recognizes that the potassium level is altered because

• Potassium is returned to extracellular fluid when metabolic acidosis is corrected.
• Hyperkalemia causes an alkalosis that results in potassium being shifted into the cells.
• Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells.
• In alkalosis, potassium is shifted into extracellular fluid to bind excessive bicarbonate.
• Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells.

A patient comes to the ED complaining of SOB and chest pain. The ABG results are: pJ 7.45, PaCO2 35 mm Hg, PaO2 60 mm Hg, HCO3 24 mEq/L. What should be the nurse's first intervention?

• Set-up for intubation
• No intervention is necessary
• Place the patient on oxygen
• Administer Sodium bicarbonate
• Place the patient on oxygen-LEAST INVASIVE

Which of the following signs/symptoms would be most consistent with the following values: pH 7.20, PaO2 106 mmHg, PaCO2 35 mmHg, HCO3 11 mEq/L.

• Diarrhea
• Shortness of Breath
• Positive guaiac stools
• Peripheral cyanosis
• Diarrhea - Loss of bicarb.

pH 7.20, PaO2 106 mmHg, PaCO2 35 mmHg, HCO3 11 mEq/L

• Respiratory Acidosis
• Metabolic Acidosis
• Respiratory Alkalosis
• Metabolic Alkalosis
• Metabolic Acidosis

pH 7.2 = low, acidic O2 106 = high CO2 35 = normal HCO3 = low ~pH & HCO3 low = Metabolic Acidosis The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

• Weight loss and dry skin.
• Flat neck and hand veins and decreased urinary output.
• An increase in blood pressure and increased respirations.
• Weakness and decreased central venous pressure.
• An increase in blood pressure and increased respirations.

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

• Sustained tissue damage
• Requires NG suction
• Has a history of Addison's disease
• Uric acid level of 9.4 mg/dL
• Requires NG suction

Potassium-rich GI fluids are lost through GI suction, placing the client at risk for hypokalemia The nurse reviews a client's electrolyte lab report and notes that the potassium level is 2.5 mEq/L. Which patterns should the nurse watch for on the ECG as a result of the lab value? SELECT ALL THAT APPLY.

• U waves
• Absent P waves
• Inverted T waves
• Depressed ST segment
• Widened QRS complex
• U waves
• Inverted T waves
• Depressed ST segment

Potassium Chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium?

SELECT ALL THAT APPLY.

• Obtain an IV infusion pump.
• Monitor urine output during administration.
• Prepare the medication for bolus administration.
• Monitor the IV site for signs of infiltration or phlebitis.
• Ensure that the medication is diluted in the appropriate volume of fluid.
• Ensure that the bag is labeled so that it read the volume of potassium in the solution.

1, 2, 4, 5, 6 ( all but #3 - never administer potassium via bolus) The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

• Twitching
• Hypoactive bowel sounds
• Negative Trousseau's sign
• Hypoactive deep tendon reflexes
• Twitching

The nurse is caring for a client with Crohn's disease who has a Ca level of 8 mg/dL. Which patterns would the nurse watch for on the ECG?

SELECT ALL THAT APPLY.

• U waves
• Widened T wave
• Prominent U wave
• Prolonged QT interval
• Prolonged ST segment

4, 5 The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L. Which patterns would the nurse watch for on the cardiac monitor as a result of the lab value?

SELECT ALL THAT APPLY

• ST depression
• Prominent U wave
• Tall peaked T waves
• Prolonged ST segment
• Widened QRS complexes

3, 5

Which client is at risk for the development of a sodium level at 130 mEq/L?

• The client who is taking diuretics.
• The client with hyperaldosteronism.
• The client with Cushing's syndrome.
• The client who is taking corticosteroids.
• The client who is taking diuretics.

130 = hyponatremia.Hyperaldosteronism, Cushing's, and corticosteroids cause HYPERnatremia.The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

• muscle twitches
• decreased urinary output
• hyperactive bowel sounds
• increased specific gravity of the urine
• hyperactive bowel sounds

Hyponatremia = Na < 135.Hyperactive bowel sounds indicate Hyponatremia, as well as muscle weakness, increased urinary output, and decreased specific gravity of urine.The other options are signs of HYPERnatremia.The nurse reviews a client's lab report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level?

• Malnutrition
• Renal insufficiency
• Hypoparathyroidism
• Tumor lysis syndrome
• Malnutrition

Normal phosphate level = 3 - 4.5 1.8 = hypophosphatemia The other options are causes of HYPERphosphatemia.The nurse is reading a primary health care provider's progress notes in the client's record and reads that the provider has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

• urinary output
• wound drainage
• integumentary output
• the GI tract
• integumentary output