Fluid and Electrolytes
What is the definition of fluid and electrolyte balance and imbalance?
Fluid and electrolyte balance is the regulation of body fluid volume, osmolality, and composition and the regulation of electrolytes by the processes of filtration, diffusion, osmosis, and selective excretion. Fluid imbalances range from decreased fluid (deficit), often causing dehydration, to excessive fluid (overload), often causing edema. Electrolyte imbalances may also occur as deficits such as hypokalemia (low serum potassium) and excesses such as hyperkalemia (high serum potassium).
What nursing assessments provide the earliest indication of impaired gas exchange?
Respiratory rate, effort, SpO₂, lung sounds, and mental status.
Which signs are most consistent with hypoglycemia?
Diaphoresis, tremors, confusion.
Which type of immunity results from receiving a vaccination?
Artificial active immunity.
Which lab values suggests infection?
Monitor laboratory test results, including: Elevated WBC count with differential (especially lymphocytes and neutrophils), Increased erythrocyte sedimentation rate (ESR), Increased C-reactive protein, Positive culture and sensitivity, Positive antigen testing for infectious agents
A client receiving IV fluids develops crackles in both lung bases, increased work of breathing, and oxygen saturation drops from 96% to 89%. What is the nurse’s priority action?
Slow or stop the IV infusion and perform a focused respiratory assessment while notifying the provider.
What interventions are used for clients for impaired gas exchange?
Treating underlying cause, use of meds (antihistamines, decongestants, glucocorticoids, bronchodilators, mucolytics, and antimicrobials), oxygen therapy, mechanical ventilation, sitting in semi fowlers, deep breathing and coughing, incentive spirometer, smoking cessation, immunizations, infection control.
Why are hospitalized clients at increased risk for hypoglycemia?
Factors include reduced intake, altered metabolism, insulin use, and delayed recognition of symptoms.
What are potential risk factors for altered immunity?
Older adults, nonimmunized adults, low socioeconomic groups, individuals with chronic conditions, meds (chemo, immunosuppressants, steroids), substance use disorder, family risk of excessive immunity, people who don’t practice a health lifestyle.
Differentiate localized infection from systemic infection.
Localized infections show redness and pain; systemic infection presents with fever, tachycardia, hypotension, and altered mental status.
A client has a serum sodium level of 128 mEq/L. Which nursing assessment finding is most important to monitor?
Changes in neurologic status such as confusion or headache.
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which oxygen device should the nurse use to deliver a precise amount of oxygen to the client?
Venturi mask
How does uncontrolled hyperglycemia impair immune function and delay wound healing?
Uncontrolled hyperglycemia impairs leukocyte chemotaxis and phagocytosis, promotes inflammation, decreases tissue perfusion, and creates an environment that supports bacterial growth, resulting in delayed wound healing and increased infection risk.
A hospitalized client has a CBC showing elevated neutrophils and an increased CRP level. How should the nurse interpret these findings?
The client is likely experiencing an acute inflammatory or infectious process.
When are transmission-based precautions required? What are nursing considerations for each transmission-based precaution?
When a pathogen is spread via contact, droplet, or airborne routes. Depend on type of precaution.
A hospitalized client has the following findings: Dry mucous membranes, Urine output averaging 20 mL/hr, Heart rate 112 bpm, and Blood pressure 92/54 mm Hg. Which fluid imbalance is the nurse most concerned about?
Fluid volume deficit.
A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.4° F), and SaO2 91% on 4L NC. Which of the following actions should the nurse take first?
Administer oxygen via a high-flow mask.
Which nursing assessment findings indicate that current glucose management strategies are ineffective?
Persistent hyperglycemia or hypoglycemia trends, delayed wound healing, recurrent or worsening infections, altered mental status, fatigue, and laboratory indicators of inflammation or infection.
A client receiving chemotherapy asks how can they protect their immune health. Which explanation by the nurse is most accurate?
Frequently perform hand hygiene, avoid crowds and sick individuals, healthy lifestyle and well balanced diet, no fresh flowers, no raw fruits/veggies.
What nursing interventions protect the sterile field?
Avoid coughing, sneezing, and talking directly over a sterile field. Advise clients to avoid sudden movements; refrain from touching supplies, drapes, or the nurse’s gloves and gown; and avoid coughing, sneezing, or talking over a sterile field. The outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile. The inner surface of the sterile drape or kit, except for that 1-inch border around the edges, is the sterile field to which other sterile items can be added. To position the field on the table surface, grasp the 1-inch border before donning sterile gloves. Discard any object that comes into contact with the 1-inch border. Touch sterile materials only with sterile gloves. Consider any object held below the waist or above the chest contaminated. Sterile materials can touch other sterile surfaces or materials; however, contact with non-sterile materials at any time contaminates a sterile area, no matter how short the contact. Do not reach across or above a sterile field. Do not turn your back on a sterile field. Hold items to add to a sterile field at a minimum of 6 inches above the field. Keep all surfaces dry. Discard any sterile packages that are torn, punctured, or wet.
A client’s morning labs reveal a potassium of 6.0 mEq/L and a creatinine level of 2.4 mg/dL. The client reports muscle weakness but denies chest pain. What nursing action takes highest priority?
Place the client on continuous cardiac monitoring and assess for ECG changes. Treat the high potassium (dialysis, Kayexelate, insulin and glucose, calcium gluconate, etc.) and promote kidney perfusion (fluids).
What are the nurse’s primary responsibilities when caring for a mechanically ventilated client?
Establish communication method; maintain a patent airway; suction, have resus bag near, frequent assessments, verify settings, monitor and intervene with alarms, prevention of VAP, monitor cuff pressure, assess for skin breakdown, provide adequate nutrition.
Prioritize the nursing actions for a client experiencing symptomatic hypoglycemia.
Assess level of consciousness, administer a rapid-acting carbohydrate (15g) if alert (give IV dextrose or glucagon if not alert), recheck blood glucose after 15 minutes, monitor for resolution of symptoms, identify the underlying cause, and implement strategies to prevent recurrence.
A client develops wheezing, facial swelling, and hypotension shortly after receiving IV antibiotics. What type of immune response is occurring, and what is the nurse’s priority?
Type I hypersensitivity reaction; maintain airway and notify the provider immediately. The nurse’s priority is to maintain airway patency and support breathing and circulation, stop the medication, administer emergency interventions per protocol, and notify the provider immediately.
Prioritize nursing actions when sepsis is suspected.
Activate sepsis protocol, obtain cultures as ordered, administer fluids and antibiotics promptly, monitor perfusion.