Nursing Assessment IV Fluids and Electrolytes

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Questions and Answers

Which assessment is most critical for the nurse to perform to determine if IV fluids are effective?

Daily weight measurement (correct)

Respiratory rate counting

Pulse quality assessment

Temperature monitoring

What findings should the nurse expect to see indicating improvement after starting IV fluids?

Decreased pulse pressure and improved skin integrity

Increased respiratory rate and diminished urine output

Increased heart rate and decreased blood pressure

Reduction in neck vein distension and stable blood pressure (correct)

Which of the following symptoms suggests the patient may be experiencing hypervolemia?

Dry oral mucosa and decreased cardiac output

Distended neck veins and bounding pulse (correct)

Decreased pulse and shallow breathing

Weight loss and fainting spells

How much fluid gain or loss corresponds to a change of 1 kg in a patient's weight?

1 liter Signup and view all the answers

Which nursing diagnosis is appropriate for a patient with fluid volume overload?

Ineffective tissue perfusion Signup and view all the answers

What is a significant management step for a patient in a hypercalcemic crisis?

Provide 3 to 4 liters of fluids per day Signup and view all the answers

Which dietary source is considered the best-absorbed source of calcium?

Dairy products Signup and view all the answers

Which of the following conditions is NOT a cause of hypomagnesemia?

Excessive magnesium intake Signup and view all the answers

What is an important nursing management consideration for IV magnesium administration?

Always dilute magnesium sulfate according to policy Signup and view all the answers

Which symptom is characteristic of hypomagnesemia?

Muscle weakness Signup and view all the answers

What does a blood pressure of 80/40 mm Hg and a thready pulse indicate about the client's condition?

The client is likely experiencing dehydration. Signup and view all the answers

Which IV fluid is appropriate for treating a client with severe dehydration and low blood pressure?

Lactated Ringer's solution Signup and view all the answers

What is the normal range for sodium (Na) levels in mEq/ml?

135-145 Signup and view all the answers

Which of the following manifestations indicates hyponatremia?

Muscle cramping and confusion Signup and view all the answers

What medical management is recommended for hypernatremia?

Replacement with hypotonic electrolyte solutions or D5W Signup and view all the answers

Which electrolyte is essential for muscle contraction and cardiac function?

Calcium (Ca) Signup and view all the answers

What is a common cause of hypernatremia?

Excess sodium administration Signup and view all the answers

Which of the following is not a recommended nursing management for hypernatremia?

Administer sodium-rich foods Signup and view all the answers

Which of the following is NOT a common cause of hypovolemia?

Increased fluid intake Signup and view all the answers

What is a key laboratory finding associated with hypovolemia?

Increased hematocrit Signup and view all the answers

What vital sign change is most likely to be observed in a patient with hypovolemia?

Tachycardia Signup and view all the answers

In managing hypovolemia, which type of fluid replacement is preferred?

Isotonic fluids like 0.9% NS Signup and view all the answers

Which of the following is a risk factor for hypovolemia?

Adrenal insufficiency Signup and view all the answers

What should the nurse monitor to assess the severity of hypovolemia?

Intake and output Signup and view all the answers

Which symptom is indicative of poor perfusion associated with hypovolemia?

Cool and clammy skin Signup and view all the answers

In the case of hypovolemia, what treatment is likely to be ordered by the healthcare provider?

Rapid infusion of isotonic fluids Signup and view all the answers

What is the daily sodium intake recommendation for cardiac patients?

2,300 mg or less Signup and view all the answers

Which of the following foods is a top dietary source of sodium?

Breads and rolls Signup and view all the answers

Which of the following is NOT a sign of hypokalemia?

Increased energy levels Signup and view all the answers

How should potassium chloride be taken to minimize gastrointestinal effects?

With a meal and at least 8 oz of water Signup and view all the answers

What is the hypokalemia threshold value for potassium levels?

< 3.5 mEq/L Signup and view all the answers

Which of the following potassium supplements is administered orally?

Potassium chloride Signup and view all the answers

What medical management strategy is typically used for severe hypokalemia?

Increased dietary potassium Signup and view all the answers

What is a critical nursing consideration when administering potassium IV infusions?

Administer at a controlled rate to prevent complications Signup and view all the answers

What should be done first when an IV catheter has dislodged into the subcutaneous space?

Discontinue the infusion and remove the catheter Signup and view all the answers

Which of the following symptoms indicates phlebitis at an IV site?

Pain and erythema along the vein Signup and view all the answers

What is the primary responsibility of the RN when dealing with IV complications?

Discontinue the IV and elevate the affected extremity Signup and view all the answers

What action should be taken if a medication is extravasated during an IV infusion?

Administer an antidote to neutralize the drug Signup and view all the answers

Which of the following is a central venous access device?

Peripherally inserted central catheter (PICC) Signup and view all the answers

How often should the IV site be assessed for a patient with a central venous access device?

Every shift and document findings Signup and view all the answers

What is a major complication associated with improper IV site care?

Increased likelihood of phlebitis Signup and view all the answers

What technique is essential for initiating an IV infusion safely?

Using aseptic technique during insertion Signup and view all the answers

Study Notes

Fundamentals of Nursing: Fluids and Electrolytes

Fluid and electrolyte balance is the body's maintenance of homeostasis of fluid volume and electrolytes.
Mechanisms include osmosis, diffusion, active transport, and capillary filtration.
Water is the primary body fluid and water content varies with age, sex, and adipose tissue.
Electrolytes have an electrical charge when dissolved in water.
Nonelectrolytes do not conduct electricity (e.g., glucose, urea).
Fluid intake is primarily through drinking fluids, and 20% from food and metabolism. Recommendations for daily intake are 2700 mL/day for women, and 3500 mL/day for men.
Fluid intake is regulated by thirst and changes in plasma osmolality, controlled by the hypothalamus.
Fluid output includes urine, skin (perspiration), lungs (exhalation), and feces. Typical daily urinary output is 1500 mL and fecal loss is 100-200 mL/day. Insensible losses include skin perspiration and water vapor from the lungs. Noticeable losses include sweat and loss through intestines. Minimal obligatory loss is 500 mL of urine in 24 hours or 30 mL in an hour.
Hormonal Regulation:
- Antidiuretic hormone (ADH) from the pituitary gland causes kidneys to retain fluid.
- Renin-angiotensin system causes kidneys to release renin and aldosterone when fluid volume decreases, increasing sodium and water reabsorption, and potassium excretion, thereby increasing plasma volume and kidney perfusion.

Body Fluid Imbalances

Fluid Volume Excess (FVE): Hypervolemia (one of the most important nursing diagnoses). Common causes are excess sodium intake, kidney or liver disease, or heart failure (decreased cardiac output). Clinical manifestations include elevated blood pressure, bounding pulse, edema, ascites, pulmonary crackles, and rapid weight gain.
Fluid Volume Deficit (FVD): Hypovolemia or dehydration. Clinical Manifestations: Thirst, decreased skin turgor, dry mucous membranes, increased pulse, orthostatic hypotension, muscle weakness, decreased urine output, concentrated urine, hypernatremia (sodium greater than 145 mEq/L), and elevated BUN.

Diagnostic Laboratory Values

Blood Urea Nitrogen (BUN): Normal level: 7-20 mg/dL. Primarily used to evaluate fluid balance, liver and kidney function. Elevated BUN levels can signify less-than-optimal kidney filtering, low fluid balance, and high protein intake/breakdown. Low levels typically indicate malnutrition due to poor protein intake.
Creatinine: Normal level: 0.6-1.2 mg/dL (varies slightly by sex). Evaluates kidneys’ filtering waste, and associated disorders can result in raised levels of creatinine. Used to monitor kidney function. When levels rise, Acute kidney injury (AKI) is potentially indicated

Fluid & Electrolyte Imbalances (Specific)

Hypovolemia & Dehydration (FVD): Causes: inadequate fluid intake, excessive fluid loss, excessive heat, altered mental status, infections. Interventions: Prevention, Encourage oral intake [2-3 litres per day] (contraindicated if necessary), limit sodium intake, monitor intake and output. Daily weights, IV fluid (slow-moderate)
Hypervolemia (FVE): Causes: excess fluids (excess sodium intake, kidney or liver disease, or heart failure (decreased cardiac output). Interventions: Monitor I & O, daily weights, IV fluid regulation, limit fluid intake.

IV Fluid Types

Isotonic: Balanced with blood, stays in the vascular space (e.g., 0.9% sodium chloride (normal saline), Lactated Ringer's (LR), D5W).
Hypotonic: Less concentrated than blood, moves into cells. (e.g., 0.45% sodium chloride (half normal saline), D5W).
Hypertonic: More concentrated than blood, pulls fluid from cells. (e.g., 3% sodium chloride (hypertonic saline), 5% dextrose in 0.9% sodium chloride, D5.9, D10).

IV Vascular Access

Peripheral Intravenous (IV): Inserted by RN. Location and size based on fluid type and treatment length/client condition. Sites: Hand, forearm, antecubital space, upper arm.
Central Venous Access Devices (CVADs): Inserted by MD. Advantages: Accommodate irritating fluids, remain longer, less phlebitis/infiltration. Disadvantages: Consent needed, X-ray required, strict sterile technique; Risks: Sepsis, air embolism, pneumothorax.

Blood Banking:

Blood typing: Inherited and determined by self-antigen and antibodies. Types: A, B, AB, O. RH factor (either positive + or negative -) is additional antigen. Type O- is universal donor and type AB+ is universal recipient.
Blood typing & cross-matching: Procedure to screen blood for any infection, and confirming recipient and donor compatibility.
Blood products: Whole Blood, Packed Red Blood Cells (PRBCs), Fresh Frozen Plasma (FFP), Platelets, White blood Cells, and Plasma Derivatives (clotting factors, immunoglobins, albumin).
Types of Blood Donatian: Standard, directed, autologous, intraoperative blood salvage.
Initiating Blood Transfusions: Procedures detailed regarding consent, prescribed rates, appropriate IV catheter size, infusion pumps, and saline prep. Assess for symptoms during and after transfusion (includes allergic, hemolytic, circulatory overload, and febrile reactions)
Transfusion Reactions: Allergic reaction (itching, wheezing, flushing), Hemolytic reaction (chills, fever, lower back pain, tachycardia/tachypnea, chest pain/tightening), Circulatory overload (respiratory distress, crackles, edema, distended neck veins, cough, anxiety, hypertension, tachycardia), Febrile reaction (temperature elevation, chills, full degree, warm flushed skin, aches), Bacterial reaction (fever, warm flushed skin, chills, vomiting).
Addressing Transfusion Reactions: Stop the transfusion immediately, remove the blood tubing, and start normal saline infusion, monitor vital signs, notify physician. Include the procedures associated with the different types of reactions.

Acid-Base Balance

Basic principles: Body's cellular activities require an alkaline medium. Normal pH of ECF is 7.35-7.45, and ratio of carbonic acid to bicarbonate is 1:20.
Respiratory Regulation: Lungs regulate acid-base balance by eliminating CO2. Hyperventilation (rapid deep breathing) removes CO2, making blood more alkaline. Hypoventilation (shallow breathing) conserves CO2 to make blood more acidic. Normal CO2 range is 35-45 mmHg.
Renal Regulation: Kidneys maintain acid-base balance by regulating bicarbonate. If serum pH is too acidic, kidneys conserve it. If too alkaline, kidneys excrete bicarbonate. Normal HCO3 range 22-26 mEq/L.
Metabolic Acidosis: Caused by acid retention or increased acid production. Symptoms: headache, confusion, weakness, nausea, vomiting and Kussmaul respirations. Treatment: identify and address underlying cause and potentially administer bicarbonate.
Metabolic Alkalosis: Caused by excessive acid loss (e.g., vomiting, gastric suction), and bicarbonate intake. Symptoms: dizziness, tingling, decreased respiratory rate and depth. Treatment: replace lost fluids using saline, identify and treat underlying cause,
Interpreting ABGs: Evaluate pH, PCO2, and HCO3 (including interpretation of compensation and abnormal findings).

Electrolyte Imbalances & Nursing Care (Specifics):

Hypokalemia: (< 3.5 mEq/L). Causes: GI losses, medications, alterations to acid-base balance, hyperaldosteronism, poor dietary intake, eating disorders (anorexia/bulimia). Symptoms: fatigue, anorexia, nausea, vomiting, cardiac dysrhythmias, muscle weakness, cramps, paresthesia, and ECG changes. Interventions include increased dietary potassium intake, oral potassium replacement, and IV potassium for severe deficits.
Hyperkalemia: (> 5 mEq/L). Causes: impaired renal function, hypoaldosteronism, tissue trauma, acidosis, or treatment related. Symptoms: Cardiac dysrhythmias, muscle weakness, respiratory impairment, paresthesia, anxiety, and ECG changes. Interventions include dietary potassium restriction, cation-exchange resin, IV calcium, insulin, or dialysis.
Hypocalcemia: (< 8.5 mg/dL). Causes: Hypoparathyroidism, malabsorption, pancreatitis, alkalosis, multiple transfusions of citrated blood, renal failure, medications. Symptoms: Tetany, circumoral numbness, hyperactive DTRs, seizures, respiratory symptoms (dyspnea/laryngospasm), abnormal clotting, anxiety. Interventions: IV calcium gluconate, calcium and vitamin D supplements, and diet.
Hypercalcemia: (> 10.5 mg/dL). Causes: Malignancy, hyperparathyroidism, immobility, bone loss. Symptoms: muscle weakness, incoordination, anorexia, constipation, nausea/vomiting, abdominal/bone pain, polyuria, thirst, kidney stones, and ECG changes. Interventions: large volumes of IV fluids, diuretics to flush excess calcium, phosphates, calcitonin, bisphosphonates.

Electrolyte and Fluid Value Ranges and Function (Review)

Sodium (Na+): 135-145 mEq/L (ECF, nerve conduction, fluid volume)
Potassium (K+): 3.5-5.0 mEq/L (ICF, muscle contraction, neural conduction)
Calcium (Ca++): 8.5-10.5 mg/dL (bone health, muscle function, blood clotting)
Magnesium (Mg++): 1.5-2.5 mEq/L (nerves and muscles, cardiac conduction)

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Description

This quiz focuses on important nursing assessments related to IV fluid therapy and electrolyte imbalances. You'll explore critical findings to identify the effectiveness of IV fluids, management of hypervolemia, as well as dietary considerations. Test your knowledge on nursing diagnoses and management steps for electrolyte crises.