Fluids and Electrolytes
What is third spacing and give 3 sign or symptom.
Third spacing: Fluid accumulation in part of body where it is not easily exchanged with ECF
Signs of third space shift
Decreased Urine output
Increased HR
Decreased BP
Decreased CVP
Edema
Increased body weight
Imbalance of Is and Os
Answer: Tachycardia, skin mottling, cyanosis, myoglobinuria, rise in end tidal carbon dioxide, elevated temperature
A patient is scheduled for surgery tomorrow morning. Which pre-operative nursing interventions are appropriate? (Select all that apply)
A) Verify informed consent is signed.
B) Allow the patient to eat a light snack 4 hours before surgery.
C) Remove jewelry, nail polish, and dentures.
D) Ensure the patient voids before transfer.
E) Give all morning medications with water unless otherwise ordered.
A
C
D
wrong:
E) Give all morning medications with water unless otherwise ordered. ❌
Not all meds are safe before surgery (e.g., anticoagulants, some antihypertensives, insulin). Only give if specifically ordered.
B) Light snack 4 hrs before ❌ → Wrong. Patients are kept NPO to prevent aspiration
ABG results:
pH: 7.25
PaCO₂: 55 mmHg
HCO₃⁻: 24 mEq/L
What’s the disorder?
pH: 7.25 → acidic
PaCO₂: 55 (high) → respiratory acid
HCO₃⁻: 24 (normal) → no metabolic involvement
👉 Uncompensated Respiratory Acidosis
(CO₂ retention, e.g., COPD, hypoventilation)
What are the 2 diseases that fall under COPD and what is the difference between the 2?
Emphysema: Caused by a loss of lung elasticity and hyperinflation of the lung and causes dyspnea
Chronic Bronchitis: Caused by inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially cigarette smoke, inflammation, vasodilation, congestion, mucosal edema, bronchospasm, affects only airways, not alveoli
increased aldosterone can cause (SATA)
A) hypernatremia
B)hypercalcemia
C)hypokalemia
D)hypermagnesia
A)hypernatremia
C)hypokalemia
Aldosterone is a "salt saver potassium pusher" (it promotes sodium absorption/reabsorption and pushed potassium out into the urine instead of sodium.)
*quick reminder: ADH is a water saver NOT salt saver!
What is dehiscence and what is Evisceration?
Answer:
Dehiscence: a partial or complete separation of the outer wound layers, sometimes described as a "splitting open of the wound"
Evisceration: A total separation of all wound layers and protrusion of internal organs through the open wound
Family members are encouraging your client to "tough it out" rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the family's wishes. Priority nursing interventions for this client should target which dimension of pain?
a. Sensory
b. Affective
c. Sociocultural
d. Behavioral
e. Cognitive
c. Sociocultural
Explanation:
The family is part of the sociocultural dimension of pain. They are influencing the client and should be included in the teaching sessions about the appropriate use of narcotics and about the adverse effects of pain on the healing process. The other dimensions should be included to help the client/family understand overall treatment plan and pain mechanism
ABG results:
pH: 7.50
PaCO₂: 30 mmHg
HCO₃⁻: 24 mEq/L
What’s the disorder?
Question 2
pH: 7.50 → alkalotic
PaCO₂: 30 (low) → respiratory alkalosis
HCO₃⁻: 24 (normal) → no compensation
👉 Uncompensated Respiratory Alkalosis
(Hyperventilation, panic attack, pain, early asthma attack)
The nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient?
A)Signs of oxygen toxicity
B)Chronic chest pain
C)A barrel chest
D)Long, thin fingers
Ans: A barrel chest
Feedback:
In COPD patients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The nurse most likely would not assess chest pain or long, thin fingers; these are not characteristic of emphysema. The patient would not show signs of oxygen toxicity unless he or she received excess supplementary oxygen.
Which electrolyte imbalance would a patient who is quadriplegic and wheelchair bound be most prone to?
A) hypocalcemia
B)hypercalcemia
C)Hyponatremia
d)Hypernatremia
B) Hypercalcemia
Why? immobility promotes bone breakdown causes an increased released calcium into the bloodstream causing hypercalcemia.
The nurse is preparing a patient for surgery. Which goal is a priority for assessing the patient before surgery?
a. Plan for care after the procedure.
b. Establish a patient's baseline of normal function.
c. Educate the patient and family about the procedure. d. Gather appropriate equipment for the patient's needs.
b. Establish a patient's baseline of normal function.
When applying the principles of pain treatment, what is the first consideration?
a) Treatment is based on client goals.
b) A multidisciplinary approach is needed.
c) The client must be believed about perceptions of own pain.
d) Drug side effects must be prevented and managed.
c) The client must be believed about perceptions of own pain.
ABG results:
pH: 7.30
PaCO₂: 40 mmHg
HCO₃⁻: 18 mEq/L
What’s the disorder?
pH: 7.30 → acidic
PaCO₂: 40 (normal)
HCO₃⁻: 18 (low) → metabolic cause
👉 Uncompensated Metabolic Acidosis
(DKA, renal failure, diarrhea, lactic acidosis (sepsis))
Name 4 breath sounds and their characteristics
Crackles/Rales: Short popping sounds, pitch and intensity vary, can be heard during inspiration, expiration or both
Rhonchi: deep coarse sounds that have a snoring quality. Are heard primarily through expiration
Wheezes: high pitched musical sounds that can be heard during inspiration or expiration
Friction rub: Deep harsh grating or creaking sound that is usually heard more often during inspiration than expiration
True or false
A patient that has severe burns is going through third spacing and experiencing severe edema. What IV fluids would you administer?
A)lactated ringer
B) 0.45% saline
C)3% saline
C) 3% saline *hypertonic solution
Even though edema can be a s/s for hypervolemia, the patient can be experiencing hypovolemia because all of the fluid would be extracted out from their blood vessels and into their tissues (causing edema).
In order to help rebalance the osmotic pressure and bring fluid back into the blood vessels back from the tissues it is best to administer a hypertonic solution (3% saline)
* reminder:
lactated ringer = isotonic
0.45% saline = hypotonic
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?
Oxygen saturation (SaO2) of 85%
Heart rate of 84 beats/minute
Blood-tinged stools
Decreased cough and gag reflexes
Oxygen saturation (SaO2) of 85%
When caring for a young child with pain, which assessment tool is the most useful?
a) Simple description pain intensity scale
b) 0-10 numeric pain scale
c) Faces pain-rating scale
d) McGill-Melzack pain questionnaire
c) Faces pain-rating scale
ABG results:
pH: 7.47
PaCO₂: 44 mmHg
HCO₃⁻: 30 mEq/L
What’s the disorder?
pH: 7.47 → alkalotic
PaCO₂: 44 (normal)
HCO₃⁻: 30 (high) → metabolic cause
👉 Uncompensated Metabolic Alkalosis
(Vomiting, NG suction, excess antacids, diuretics)
A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?
A. Avoid contact with fur-bearing animals
B. Change filters on heating and air conditioning units frequently
C. Avoid using goose down pillows
D. Take ordered medications as scheduled
D. Take ordered medications as scheduled.
A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement?
A.)Restrict fluids and salt for 24 hours
B.)Correct the sodium deficit rapidly with salt.
C.)Administer small volumes of a hypertonic solution.
D.)Monitor the serum sodium for changes hourly.
C.)Administer small volumes of a hypertonic solution.
A nurse suspects malignant hyperthermia in a patient who underwent surgery approximately 18 hours ago. Which of the following would the nurse identify as a late, ominous sign?
A)Oliguria
B)Muscle rigidity
C)Rapid rise in body temperature
D)Tachycardia
C)Rapid rise in body temperature
A rise in body temperature is a late sign that develops rapidly, with the temperature possibly increasing 1 degree to 2 degrees C every 5 minutes and body core temperature exceeding 42 degrees C (107 degrees F). Tachycardia is often the earliest sign; muscle rigidity also is an early sign. Oliguria occurs with sympathetic nervous system stimulation.
When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress?
A.) The pump will deliver a preset amount of medication.
B.) The client should wait until the pain is severe to push the button to prevent overdose.
C.) Teach the client to avoid pushing the button multiple times because additional doses will be given.
D.) Chance of sedation is rare when using a PCA pump.
A.) The pump will deliver a preset amount of medication.
ABG results:
pH: 7.18
PaCO₂: 60 mmHg
HCO₃⁻: 32 mEq/L
What’s the disorder?
pH: 7.18 → acidic
PaCO₂: 60 (very high) → respiratory acidosis
HCO₃⁻: 32 (elevated) → metabolic system is trying to compensate
👉 Partially Compensated Respiratory Acidosis
(e.g., long-standing COPD exacerbation)
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?
A)Cough
B)Tachypnea
C)Hemoptysis
D)Syncope
B)Tachypnea
Explanation:
Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).