Fluid & Electrolyte Imbalances
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?
A. Weight loss and dry skin
B. Flat neck and hand veins and decreased urinary output
C. An increase in blood pressure and increased respirations
D. Weakness and decreased central venous pressure (CVP)
C. An increase in blood pressure and increased respirations
A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.
Which arterial blood gas (ABG) values would the nurse anticipate in the client with a bowel obstruction who has a nasogastric tube attached to continuous suction?
A. pH 7.25, Paco2 55, HCO3 24
B. pH 7.30, Paco2 38, HCO3 20
C. pH 7.48, Paco2 30, HCO3 23
D. pH 7.49, Paco2 38, HCO3 30
D. pH 7.49, Paco2 38, HCO3 30
The anticipated ABG finding in the client with a nasogastric tube to continuous suction is metabolic alkalosis resulting from loss of acid. In uncompensated metabolic alkalosis, the pH will be elevated (greater than 7.45), bicarbonate will be elevated (greater than 28 mEq/mL), and the Paco2 will most likely be within normal limits (35 to 45 mm Hg).
The nurse is encouraging the client to cough and deep breathe after cardiac surgery to avoid developing pneumonia. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
A. Nebulizer
B. Ambu bag
C. Suction equipment
D. Incisional splinting pillow
D. Incisional splinting pillow
The use of an incisional splint such as a "cough pillow" can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options A, B, and C will not encourage the client to cough and deep breathe.
A client is hospitalized with chest pain and suspected myocardial infarction. The client has a return of chest pain, and the nurse administers one 0.4-mg nitroglycerin tablet sublingually as prescribed. Which nursing action would the nurse implement next if the chest pain is not relieved?
A. Administer morphine sulfate
B. Increase the oxygen flow rate
C. Place the client in Trendelenburg's position
D. Administer a second sublingual nitroglycerin tablet in 5 minutes
D. Administer a second sublingual nitroglycerin tablet in 5 minutes
Unless otherwise prescribed, nitroglycerin tablets are administered 1 every 5 minutes, not exceeding 3 tablets, for chest pain as long as the client maintains a systolic blood pressure of 100 mm Hg or greater. The primary health care provider is notified if the chest pain is not relieved after administering the 3 tablets. Placing the client in Trendelenburg's (head lowered) position may be necessary with sudden drops in blood pressure, at which time the primary health care provider would be notified. Administering morphine sulfate or increasing oxygen flow rate would be done with a prescription from a primary health care provider.
A client prescribed albuterol sulfate by inhalation cannot cough up secretions. The nurse would teach the client which action to best help clear the bronchial secretions?
A. Get more exercise each day.
B. Use a dehumidifier in the home.
C. Administer an extra dose before bedtime.
D. Increase the amount of fluids consumed every day.
D. Increase the amount of fluids consumed every day.
The client should take in increased fluids (2000 to 3000 mL/day unless contraindicated) to make secretions less viscous. This may help the client expectorate secretions. This is standard advice given to clients receiving any of the adrenergic bronchodilators, such as albuterol, unless the client has another health problem that could be worsened by increased fluid intake. Additional exercise will not effectively clear bronchial secretions. A dehumidifier will dry secretions. The client would not be advised to take additional medication.
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?
A. Sustained tissue damage
B. Requires nasogastric suction
C. Has a history of Addison's disease
D. Uric acid level of 9.4 mg/dL (559 mmol/L)
B. Requires nasogastric suction
The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia
The nurse is reviewing the client's arterial blood gas results. Which finding would indicate that the client is experiencing respiratory acidosis?
A. pH 7.5, Pco2 of 30
B. pH 7.3, Pco2 of 50
C. pH 7.3, HCO3 of 19
D. pH 7.5, HCO3 of 30
B. pH 7.5, HCO3 of 30
In respiratory acidosis, the pH is decreased and an opposite effect is seen in the Pco2 (pH decreased, Pco2 elevated). Option A indicates respiratory alkalosis; option C indicates possible metabolic acidosis; option D indicates possible metabolic alkalosis.
The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position?
A. Sit bolt upright in bed with the arms crossed over the chest.
B. Lie on the side with the head of the bed at a 45-degree angle.
C. Sit in a reclining chair tilted slightly back with the feet elevated.
D. Sit on the edge of the bed with the arms leaning on an overbed table.
D. Sit on the edge of the bed with the arms leaning on an overbed table.
Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Sitting bolt upright with arms folded across the chest restricts the movement of the anterior and posterior walls of the lung, and side-lying with the head of bed raised to a 45-degree position restricts the expansion of the lateral wall of the lung. Option C restricts posterior lung expansion.
The nurse in an ambulatory care clinic takes a client's blood pressure (BP) in the left arm; it is 200/118 mm Hg. Which action would the nurse take next?
A. Notify the primary health care provider.
B. Inquire about the presence of kidney disorders.
C. Check the client's blood pressure in the right arm.
D. Recheck the pressure in the same arm within 30 seconds.
C. Check the client's blood pressure in the right arm.
When a high BP reading is noted, the nurse takes the pressure in the opposite arm to see if the blood pressure is elevated in one extremity only. The nurse would also recheck the blood pressure in the same arm but would wait at least 2 minutes between readings. The nurse would inquire about the presence of kidney disorders that could contribute to the elevated blood pressure. The nurse would notify the primary health care provider because immediate treatment may be required, but this would not be done without obtaining verification of the elevation.
The nurse monitors a client prescribed a thiazide diuretic as part of treatment from hypertension for which clinical manifestations of hypokalemia? Select all that apply.
A. Muscle twitches
B. Deep tendon hyporeflexia
C. Prominent U wave on ECG
D. General skeletal muscle weakness
E. Hypoactive to absent bowel sounds
F. Tall T waves on electrocardiogram (ECG)
B. Deep tendon hyporeflexia, C. Prominent U wave on ECG, D. General skeletal muscle weakness, E. Hypoactive to absent bowel sounds
Hypokalemia is a serum potassium level less than 3.5 mEq/L (3.5 mmol/L). Clinical manifestations include ECG abnormalities such as ST depression, inverted T wave, prominent U wave, and heart block. Other manifestations include deep tendon hyporeflexia, general skeletal muscle weakness, decreased bowel motility and hypoactive to absent bowel sounds, shallow ineffective respirations and diminished breath sounds, polyuria, decreased ability to concentrate urine, and decreased urine specific gravity. Tall T waves and muscle twitches are manifestations of hyperkalemia.
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
A. Twitching
B. Hypoactive bowel sounds
C. Negative Trousseau's sign
D. Hypoactive deep tendon reflexes
A. Twitching
The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
The nurse is reviewing the arterial blood gas (ABG) results of a client in the respiratory care unit and notes a pH of 7.38; Pco2, 38 mm Hg; Po2, 86 mm Hg; and HCO3, 23 mEq/L. The nurse would interpret that the client's blood gases indicate which finding?
A. Normal results
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory acidosis
A. Normal results
The client's results fall in the normal range for pH (7.35 to 7.45), Pco2 (35 to 45), and bicarbonate level (22 to 26 mEq/L). With acidosis, the pH is less than 7.35; with alkalosis, the pH is greater than 7.45. Carbon dioxide levels are high with respiratory acidosis, whereas bicarbonate levels are low if there is metabolic acidosis.
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding?
A. Loud wheezing
B. Wheezing on expiration
C. Noticeably diminished breath sounds
D. Increased displays of emotional apprehension
C. Noticeably diminished breath sounds
Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. Also, the client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress is being experienced.
A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats/min. The nurse would assess the client for which effects of this cardiac occurrence? Select all that apply.
A. Dyspnea
B. Flat neck veins
C. Nausea and vomiting
D. Chest pain or discomfort
E. Hypotension and dizziness
F. Hypertension and headache
A. Dyspnea, D. Chest pain or discomfort, E. Hypotension and dizziness
The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats/min is at risk for low cardiac output caused by loss of atrial kick. The nurse should assess the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Neither headache nor nausea and vomiting are directly associated with the effects of uncontrolled atrial fibrillation.
A client with acute kidney injury had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of 19 mEq/L (19 mmol/L). Which disorder would the nurse interpret that the client is experiencing?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
A. Metabolic acidosis
Metabolic acidosis occurs when the pH falls to less than 7.35 and the bicarbonate level falls to less than 22 mEq/L (22 mmol/L). With metabolic alkalosis, the pH rises to more than 7.45 and the bicarbonate level rises to more than 27 mEq/L (27 mmol/L). With respiratory acidosis, the pH drops to less than 7.35 and the carbon dioxide level rises to more than 45 mm Hg. With respiratory alkalosis, the pH rises to more than 7.45 and the carbon dioxide level falls to less than 35 mm Hg.
The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply.
A. Bounding pulse
B. Difficulty breathing
C. Increased urine output
D. Presence of dependent edema
E. Neck vein distention in the upright position
A. Bounding pulse, B. Difficulty breathing, D. Presence of dependent edema, E. Neck vein distention in the upright position
Care of a client with HF and fluid overload includes monitoring for bounding pulses, difficulty breathing, neck vein distention in the upright position, and dependent edema. Increased urine output is not associated with HF and fluid overload.
The nurse is reviewing the arterial blood gas results of a client. Blood gas results indicate a pH of 7.30 and a Pco2 of 50 mm Hg. Based on these results, the nurse has determined that the client is experiencing respiratory acidosis. Which additional laboratory value would the nurse expect to note in this client?
A. Potassium 5.4 mEq/L (5.4 mmol/L)
B. Magnesium 2 mEq/L (1.0 mmol/L)
C. Sodium of 145 mEq/L (145 mmol/L)
D. Phosphorus 2.3 mEq/L (0.74 mmol/L)
A. Potassium 5.4 mEq/L (5.4 mmol/L)
Clinical manifestations of respiratory acidosis include dyspnea, disorientation or coma, dysrhythmias, hyperkalemia, and hypoxemia. The sodium, magnesium, and phosphorus would remain within normal range.
The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action?
A. Loosens the abdominal muscles while breathing out
B. Breathes in and then holds the breath for 30 seconds
C. Inhales with puckered lips and exhales with the mouth open wide
D. Breathes so that expiration is two to three times as long as inspiration
D. Breathes so that expiration is two to three times as long as inspiration
COPD is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing.
A client experiencing difficulty breathing and increased pulmonary congestion as a result of heart failure was prescribed furosemide 40 mg to be given intravenously. After an hour which assessment finding indicates that the therapy has been effective?
A. The lungs are now clear upon auscultation.
B. The urine output has increased by 400 mL.
C. The blood pressure has decreased from 118/64 to 106/62 mm Hg.
D. The serum potassium has decreased from 4.7 to 4.1 mEq (4.7 to 4.1 mmol/L).
A. The lungs are now clear upon auscultation.
Furosemide is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option A is the reason that the furosemide was administered.
A client just diagnosed with acute kidney injury has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which action should the nurse take immediately?
A. Check the sodium level.
B. Call the primary health care provider.
C. Encourage an extra 500 mL of fluid intake.
D. Teach the client about foods low in potassium.
B. Call the primary health care provider.
The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the primary health care provider must be notified at once so that the client may receive definitive treatment. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse. Fluid intake would not be increased because it would contribute to fluid overload and would not effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority.
The nurse plans care for a client with dehydration requiring intravenous (IV) fluids and electrolytes understanding that which are findings that correlate with the need for this type of therapy? Select all that apply.
A. Hyponatremia
B. Bounding pulse rate
C. Chronic kidney disease
D. Isolated syncope episodes
E. Rapid, weak, and thready pulse
F. Abnormal serum and urine osmolality levels
A. Hyponatremia, E. Rapid, weak, and thready pulse, F. Abnormal serum and urine osmolality levels
Abnormal assessment findings of major body systems offer clues to fluid and electrolyte imbalances. Rapid, weak, and thready pulse is an assessment abnormality found with fluid and electrolyte imbalances, such as hyponatremia. Abnormal serum and urine osmolality are laboratory tests that are helpful in identifying the presence of or risk of fluid imbalances. Isolated episodes of syncope are not indicators for intravenous therapy unless fluid and electrolyte imbalances are identified. A bounding pulse rate is a manifestation of fluid volume excess; therefore, IV fluids are not indicated. Clients with chronic kidney disease experience the inability of the kidneys to regulate the body's water balance; fluid restrictions may be used.
A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse would assess this client for which signs/symptoms characteristic of this disorder?
A. Drowsiness, headache, and tachypnea
B. Tachypnea, dizziness, and constipation
C. Disorientation, dyspnea, and increased respiratory rate
D. Decreased respiratory depth and rate and dysrhythmias
D. Decreased respiratory depth and rate and dysrhythmias
The client with metabolic alkalosis is likely to exhibit a decrease in respiratory rate and depth; nausea, vomiting, and diarrhea; restlessness; numbness and tingling in the extremities; twitching in the extremities; hypokalemia; hypocalcemia; and dysrhythmias. None of the remaining options are associated with metabolic alkalosis.
The nurse is teaching a client to self-administer inhaled fluticasone and albuterol for the treatment of asthma. Which statement by the client would indicate that teaching has been effective?
A. "I'll keep the inhalers in the refrigerator."
B. "I can use an inhaler for a week past the expiration date."
C. "I will take the albuterol first, wait a few minutes, and then take the fluticasone."
D. "I will take the fluticasone first, wait a few minutes, and then take the albuterol."
C. "I will take the albuterol first, wait a few minutes, and then take the fluticasone."
When these two medications are taken together, the bronchodilator (albuterol) should be given first to open the airways. This will allow better penetration of the corticosteroid into the bronchial tree. Inhalers do not need to be refrigerated, and no medication should be taken past the expiration date.
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead electrocardiogram (ECG). Which action would the nurse take first?
A. Obtain the 12-lead ECG.
B. Draw the blood specimens.
C. Apply oxygen to the client.
D. Schedule the chest x-ray study.
C. Apply the oxygen to the client.
The first action would be to apply the oxygen because the client can be experiencing myocardial ischemia. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, oxygen is the priority to prevent further cardiac damage. Drawing the blood specimens would be done after oxygen administration and just before or after the ECG, depending on the situation. Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment.
The nurse finds that a client with hypervolemia has a serum sodium level of 129 mEq/L (129 mmol/L). As prescribed, which intervention would the nurse plan to implement to restore the client's fluid and electrolyte balance gradually?
A. A loop diuretic
B. A fluid restriction plan
C. A 2-gram sodium diet
D. A 4-gram sodium diet
2. A fluid restriction plan
A serum sodium level of less than 135 mEq/L (135 mmol/L) means that the client is hyponatremic; when it is caused by hypervolemia, hyponatremia is the result of hemodilution. Therefore, fluid restriction is indicated to restore fluid and electrolyte balance gradually by increasing the relative serum sodium level as the client excretes water. Option A is unlikely to restore fluid and electrolyte balance, because loop diuretics excrete sodium and water; in addition, the fluid shifts are likely to occur within hours instead of gradually. A 2-gram sodium diet is a sodium-restricted diet, and a 4-gram sodium diet is a no-added-salt diet; both diets are unlikely to increase the serum sodium.