Fluid &
Electrolyte Balance/Acid Base
Balance
Electrolyte Balance/Acid Base
Balance
Electrolyte lab values
Sodium: 136 - 145 mEq/L
Potassium 3.5 - 5.0 mEq/L
Calcium 9.0 - 10.5 mg/dL
Chloride 98 - 106 mEq/L
Magnesium 1.3 - 2.1 mEq/L
The nurse who is starting the shift finds a client with an IV that is leaking on the bed linens. What will the nurse do first?
Assess the insertion site
- The initial response by the nurse is to assess the insertion site. The purpose of this action is to check for patency, which is the priority. IV assessments typically begin at the insertion site and move “up” the line from the insertion site to the tubing, to the tubing’s connection to the bag. Checking the IV connection is important, but is not the priority in this situation. Checking the infusion rate is not the priority. Discontinuing the IV to start another may be required, but it may be possible to “save” the IV, and the problem may be positional or involve a loose connection.
The nurse is providing discharge teaching to a postoperative patient. Which instruction about activity is most appropriate?
A) Resume all normal activities immediately
B) Avoid all physical activity for 6 weeks
C) Increase activity level slowly and rest often
D) Perform vigorous exercise to prevent complications
C) Increase activity level slowly and rest often
Rationale: Surgery stresses the body, and time and rest are needed for healing. Patients should increase activity levels slowly, rest often, and avoid straining the wound or surrounding area.
The nurse is teaching a patient with decreased immunity about infection prevention. Which instruction should be included? (Select all that apply)
A) Avoid large crowds
B) Wash hands frequently
C) Use hand sanitizer when soap is unavailable
D) Avoid anyone with transmittable illness
E) Increase exposure to build immunity
A, B, C, D
Rationale: Patients with decreased immune systems are very prone to infection and should avoid crowds, wash hands frequently, use hand sanitizer, and avoid people with transmittable diseases.
A nurse is assessing a postoperative patient's surgical drain on the second day after surgery. The drainage is blood-tinged with a yellowish tint. How should the nurse document this finding?
A) Sanguineous drainage
B) Serosanguineous drainage
C) Serous drainage
D) Purulent drainage
B) Serosanguineous drainage
Rationale: Serosanguineous drainage is yellowish mixed with light red or pale pink. This is normal during the first few days after surgery as drainage changes from sanguineous (bloody) to serosanguineous to serous (serum-like or yellow).
1. The nurse is caring for a client with a hematocrit of 57% and a sodium level of 149 mEq/L. How would the nurse interpret this data?
2. The nurse is caring for a client who has a serum potassium level of 2.9 mEq/L. Which assessment is appropriate?
1. The client is experiencing relative hypernatremia.
- The serum sodium level is elevated, indicating hypernatremia. The elevation could be from an actual increase in sodium or from a loss of fluids only. Relative hypernatremia can occur as a result of dehydration (excessive fluid loss) without sodium loss.
2. Determining what drugs are taken daily
- The serum potassium level is low, and the client has hypokalemia. Misuse or overuse of diuretics, especially loop and thiazide diuretics, is a common cause of hypokalemia
The nurse is teaching a course about the special needs of older adults receiving IV therapy. What teaching will the nurse include?
Skin integrity can be compromised easily by the application of tape or dressings.
- Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity. Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client’s vein. Clipping, and not shaving, the hair around the insertion site typically is necessary only for younger men.
A nurse is caring for a postoperative patient on the medical-surgical floor. Which respiratory assessment finding requires immediate intervention?
A) Respiratory rate of 18 breaths/min
B) SpO₂ of 96% on room air
C) Respiratory rate of 8 breaths/min
D) Use of incentive spirometer every 2 hours
C) Respiratory rate of 8 breaths/min
Rationale: A respiratory rate of less than 10 breaths/min may indicate anesthetic- or opioid analgesic-induced respiratory depression and requires immediate intervention to prevent hypoxia.
A patient develops urticaria, angioedema, and wheezing immediately after receiving penicillin. Which type of hypersensitivity reaction is this?
A) Type I (Immediate)
B) Type II (Cytotoxic)
C) Type III (Immune Complex)
D) Type IV (Delayed)
A) Type I (Immediate)
Rationale: Type I hypersensitivity reactions occur within minutes to hours after exposure to an antigen. Symptoms include urticaria, angioedema, wheezing, and anaphylaxis. These reactions are mediated by IgE antibodies and mast cell degranulation.
Which wound drainage characteristic requires immediate notification of the surgeon?
A) Serous drainage on day 5
B) Serosanguineous drainage on day 2
C) Purulent, odorous drainage
D) Minimal sanguineous drainage on day 1
C) Purulent, odorous drainage
Rationale: Purulent or odorous drainage indicates surgical site infection (SSI) and must be reported to the surgeon. Other signs of infection include redness/hyperpigmentation, excessive swelling, and increased tenderness or pain.
1. Which client would the nurse monitor closely for the development of respiratory acidosis?
A. Client who continually takes antacids
B. Client receiving IV normal saline bolus
C. Client whose urinary output has increased
D. Client with rib fractures following a motor vehicle accident
2. The grasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. Which action would the nurse take first?
A. Determine the oxygen saturation.
B. Measure pulse and blood pressure.
C. Notify the Rapid Response Team.
D. Apply humidified oxygen by nasal cannula.
1. Answer: D
Rationale: Respiratory acidosis can occur in clients with hypermetabolism, which can develop with impaired gas exchange due to rib fractures (Choice D). The client taking continuous antacids is more likely to develop alkalosis than acidosis (Choice A). Intravenous saline boluses (Choice B) and increased urinary output (Choice C) are not associated with acid-base imbalances.
2. Answer: A
Rationale: When a client’s status changes, the initial action is to perform assessments. Metabolic acidosis involves the overproduction of hydrogen ions, which can occur in the presence of hypoxia. The nurse will determine the client’s oxygen saturation first (Choice A). All other actions (Choices B, C, and D) can be taken subsequent to determining the severity and status of the client’s presentation
A nurse is preparing to administer an isotonic IV solution to a 78-year-old patient. Which patient risk should the nurse monitor for closely?
A) Cellular dehydration
B) Fluid overload
C) Hyponatremia
D) Metabolic acidosis
B) Fluid overload
Rationale: When an isotonic solution is infused, water does not move into or out of the body's cells and remains in the extracellular compartments. Patients, especially older adults, receiving isotonic solutions are at risk for fluid overload.
Which assessment finding is the most sensitive early indicator of malignant hyperthermia?
A) Body temperature of 111.2°F (44°C)
B) Muscle rigidity of jaw and upper chest
C) Elevated end-tidal CO₂ with decreased SpO₂ and tachycardia
D) Myoglobinuria and skin mottling
C) Elevated end-tidal CO₂ with decreased SpO₂ and tachycardia
Rationale: The most sensitive indication of malignant hyperthermia is an unexpected rise in end-tidal carbon dioxide level with a decrease in oxygen saturation and tachycardia. Extremely elevated temperature is a late sign of MH.
Which assessment finding indicates a Type IV (delayed) hypersensitivity reaction?
A) Wheezing within 30 minutes of exposure
B) Localized skin rash 48-72 hours after contact with allergen
C) Hemolytic anemia after blood transfusion
D) Fever and joint pain
B) Localized skin rash 48-72 hours after contact with allergen
Rationale: Type IV reactions are cell-mediated and delayed, typically appearing 24-72 hours after exposure. Contact dermatitis is a common example.
A patient with dark skin is at risk for pressure injury. Which assessment technique is most appropriate?
A) Assess only for blanching
B) Assess for skin temperature, edema, pain, and induration
C) Visual inspection is sufficient
D) Pressure injuries cannot be assessed in dark skin
B) Assess for skin temperature, edema, pain, and induration
Rationale: In patients with dark skin, assess for blanching, skin temperature, edema presence or absence, pain, and induration. These techniques provide a more comprehensive assessment than visual inspection alone.
1. The nurse is caring for a client being mechanically ventilated whose ventilation rate was too high for several hours. Which acid–base problem does the nurse expect?
2. Which client arterial blood pH value indicates to the nurse the lowest concentration of free hydrogen ions? (normal blood pH = 7.35-7.45)
1. Respiratory alkalosis
A ventilator set at either too high a ventilation rate and/or at too great a tidal volume will cause the client to lose too much carbon dioxide, leading to an acid-deficit respiratory alkalosis.
2. Answer: 7.45
- The concentration of hydrogen ions is inversely (negatively) related to the pH. Thus the lower the pH, the higher the concentration of hydrogen ions and the higher the pH, the lower the concentration of free hydrogen ions. The pH of 7.27 represents the greatest concentration of free hydrogen ions in this list and the pH of 7.45 represents the lowest concentration of free hydrogen ions.
Total parenteral nutrition (TPN) has an osmolarity greater than 1400 mOsm/L. Where should TPN be administered?
A) Peripheral IV in the forearm
B) Peripheral IV in the hand
C) Central circulation
D) Subcutaneous tissue
C) Central circulation
Rationale: TPN should never be infused in peripheral circulation because it can damage blood cells and the endothelial lining of the veins and decrease perfusion. Fluids with osmolarity more than 600 mOsm/L are best infused in central circulation where greater blood flow provides adequate hemodilution.
A patient in the postanesthesia care unit suddenly develops tachycardia, muscle rigidity, and an elevated end-tidal CO₂ level. What is the priority nursing action?
A) Administer oxygen via non-rebreather mask
B) Notify the surgeon and anesthesia provider immediately
C) Apply cooling blankets to reduce body temperature
D) Increase IV fluid rate to prevent dehydration
B) Notify the surgeon and anesthesia provider immediately
Rationale: These symptoms indicate malignant hyperthermia (MH), an acute, life-threatening emergency. The most sensitive indication is an unexpected rise in end-tidal carbon dioxide with decreased oxygen saturation and tachycardia. Survival depends on early diagnosis and immediate action by the entire surgical team. Dantrolene sodium must be administered immediately.
A patient with HIV is prescribed antiretroviral therapy. What is the most important teaching point?
A) Take medications only when symptoms appear
B) Medication adherence is critical to prevent resistance
C) Stop medications if side effects occur
D) Share medications with partners who are also HIV positive
B) Medication adherence is critical to prevent resistance
Rationale: Strict adherence to antiretroviral therapy is essential to maintain viral suppression and prevent drug resistance. Missing doses can lead to treatment failure and disease progression.
Types of infected wound exudate
Creamy yellow pus - Colonization with Staphylococcus
Greenish-blue pus causing staining of dressings and accompanied by a “fruity” odor - Colonization with Pseudomonas
Beige pus with a “fishy” odor- Colonization with Proteus
Brownish pus with a “fecal” odor - Colonization with aerobic coliform and Bacteroides (usually occurs after intestinal surgery)
1. The nurse is caring for four clients. Which client is being monitored for respiratory acidosis?
2. The nurse is caring for a client with acute respiratory failure and respiratory acidosis with a PaCO2 level of 87 mm Hg. Which symptoms will the nurse anticipate?
1. Client who has multiple rib fractures
- A client with multiple rib fractures may have poor gas exchange from shallow breathing because of pain and because the rib fractures may inhibit adequate chest expansion. A client who is anxious and breathing rapidly is at risk for respiratory alkalosis, not acidosis. A normal saline bolus does not result in respiratory acidosis. An increased urinary output would not be a stimulus for a respiratory acid–base imbalance.
2. Hypotension, Lethargy, Acute confusion
- When caring for a client with acute respiratory failure and respiratory acidosis, the nurse anticipates hypotension, lethargy, and acute confusion. Clients with acidosis have problems associated with decreased excitable tissues, decreased perfusion, impaired memory and cognition, increased risk for falls, and reduced neuromuscular responses (not hyperactive deep tendon reflexes). Acute confusion occurs because of reduced gas exchange and reduced cognition. The pH will be below 7.35, which is a characteristic of acidosis; a pH of 7.49 indicates alkalosis.
A patient is receiving a hypotonic IV solution. Which complications should the nurse monitor for? (Select all that apply)
A) Phlebitis
B) Fluid deficit
C) Infiltration
D) Hypernatremia
E) Cellular swelling
A, C, E
Rationale: Patients receiving hypotonic fluids are at risk for phlebitis (inflammation of a vein) and infiltration (IV solution leaking into tissues). Hypotonic infusates move water into cells to expand them, which can cause cellular swelling.
A patient is prescribed antibiotics at discharge following surgery. What is the most important teaching point?
A) Take the antibiotic with food to prevent nausea
B) Complete the entire prescription even if you feel better
C) Stop the antibiotic if you experience any side effects
D) Save leftover antibiotics for future infections
B) Complete the entire prescription even if you feel better
Rationale: If antibiotics are prescribed, the nurse should stress the importance of completing the entire prescription, even if the patient feels better. This prevents antibiotic resistance and ensures complete treatment of any infection.
A patient with systemic lupus erythematosus (SLE) is experiencing a flare-up. What is the expected outcome of interprofessional collaborative management?
A) Complete cure of the disease
B) Decrease symptoms and promote quality of life
C) Prevent all future exacerbations
D) Eliminate the need for medications
B) Decrease symptoms and promote quality of life
Rationale: Autoimmune diseases like lupus typically have remissions and exacerbations (flare-ups). The expected outcome of treatment is to decrease symptoms and promote quality of life. In some cases remission can be achieved, but not a cure.
A patient with osteomyelitis has copious wound drainage. What precautions should the nurse implement?
A) Droplet Precautions
B) Airborne Precautions
C) Contact Precautions
D) Standard Precautions only
C) Contact Precautions
Rationale: In the presence of copious wound drainage, follow Contact Precautions to prevent the spread of the offending organism to other patients and health care personnel. This is especially important with infections like osteomyelitis.