Fundamentals Module 2B

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Questions and Answers

A patient with dehydration is likely to exhibit which set of vital signs?

  • Hyperthermia, tachycardia, thready pulse, hypotension (correct)
  • Hypothermia, bradycardia, strong pulse, hypertension
  • Afebrile, normal heart rate, strong pulse, normal blood pressure
  • Hypothermia, bradycardia, bounding pulse, hypertension

A nurse is assessing a patient for fluid volume excess. Which finding is most indicative of this condition?

  • Thready pulse, hypotension, and dry mucous membranes.
  • Flattened neck veins, poor skin turgor, and decreased urine output.
  • Bounding pulse, hypertension, and crackles in the lungs. (correct)
  • Weak pulse, orthostatic hypotension and tenting.

Which nursing intervention is most important when caring for a dehydrated patient?

  • Monitoring intake and output and encouraging oral rehydration. (correct)
  • Restricting fluid intake to prevent fluid overload.
  • Encouraging a high sodium diet.
  • Administering diuretics as prescribed.

A patient presents with confusion, muscle weakness, and seizures. Lab results show a serum sodium level of 128 mEq/L. Which condition is most likely?

<p>Hyponatremia (B)</p> Signup and view all the answers

A patient is diagnosed with hyperkalemia. Which ECG finding is most concerning?

<p>Peaked T waves (A)</p> Signup and view all the answers

A nurse is educating a patient with hypokalemia about dietary sources of potassium. Which food should the nurse recommend?

<p>Baked potato. (B)</p> Signup and view all the answers

The nurse is assessing a patient with suspected hypocalcemia. Which assessment finding supports this diagnosis?

<p>Positive Chvostek's sign. (C)</p> Signup and view all the answers

A patient with a history of chronic obstructive pulmonary disease (COPD) is admitted with respiratory distress. Arterial blood gas results show a PaCO2 of 50 mm Hg and a pH of 7.30. Which acid-base imbalance is most likely?

<p>Respiratory acidosis (B)</p> Signup and view all the answers

Which of the following IV solutions is most appropriate for a patient experiencing dehydration with hypotension?

<p>0.9% sodium chloride (NS). (B)</p> Signup and view all the answers

A nurse is caring for an elderly patient receiving intravenous fluid therapy. Which nursing consideration is most important to prevent fluid overload?

<p>Monitoring intake and output and assessing for edema (D)</p> Signup and view all the answers

A patient with a serum sodium level of 150 mEq/L is most likely experiencing which of the following?

<p>Hypernatremia (C)</p> Signup and view all the answers

Which electrolyte imbalance is most likely to result from excessive vomiting or nasogastric suctioning?

<p>Metabolic alkalosis (C)</p> Signup and view all the answers

A patient is prescribed a diuretic that increases potassium excretion. Which electrolyte level should the nurse monitor most closely?

<p>Potassium (B)</p> Signup and view all the answers

When evaluating fluid balance in a patient, which of the following intake and output (I&O) patterns should alert the nurse to potential dehydration?

<p>Intake of 1000 mL, output of 1500 mL in 24 hours (D)</p> Signup and view all the answers

Which finding would the nurse expect to see in a patient experiencing hypercalcemia?

<p>Decreased deep tendon reflexes and constipation (B)</p> Signup and view all the answers

A patient with a history of heart failure is receiving intravenous normal saline at 150 mL/hr. Which assessment finding requires immediate nursing intervention?

<p>All of the above (D)</p> Signup and view all the answers

A patient with metabolic acidosis is likely to exhibit which respiratory pattern as a compensatory mechanism?

<p>Rapid, deep breaths (Kussmaul respirations) (C)</p> Signup and view all the answers

Which of the following nursing interventions is most appropriate for a patient experiencing respiratory alkalosis due to anxiety?

<p>Encouraging slow, deep breathing (A)</p> Signup and view all the answers

A patient receiving a blood transfusion develops burning pain and redness at the IV site. Which complication should the nurse suspect?

<p>Phlebitis (B)</p> Signup and view all the answers

An older adult patient is receiving IV fluids. Which nursing action is most important to prevent complications related to the patient's cardiovascular system?

<p>Monitoring for signs of fluid overload (A)</p> Signup and view all the answers

A patient is diagnosed with hypokalemia. Which assessment finding would the nurse correlate with this electrolyte imbalance?

<p>Weakness and hypoactive reflexes (B)</p> Signup and view all the answers

Which of the following food choices is most appropriate for a patient trying to increase their potassium intake?

<p>Spinach (D)</p> Signup and view all the answers

A dehydrated patient is prescribed an IV solution. Which of the following parameters indicates that the rehydration therapy is effective?

<p>Improved gait stability (B)</p> Signup and view all the answers

A patient with hypernatremia is being educated about dietary modifications. Which food should the patient limit?

<p>Roasted ham (D)</p> Signup and view all the answers

Which nursing intervention is most appropriate when administering IV fluids to an elderly patient to prevent fluid overload?

<p>Monitoring intake and output closely (C)</p> Signup and view all the answers

Which assessment finding in a patient post-thyroidectomy should prompt the nurse to suspect hypocalcemia?

<p>Positive Chvostek's sign (D)</p> Signup and view all the answers

A patient with chronic kidney disease is at risk for developing which acid-base imbalance?

<p>Metabolic acidosis (B)</p> Signup and view all the answers

A patient is diagnosed with fluid volume overload. The nurse would expect to find which of the following vital sign changes?

<p>Hypertension and tachycardia (B)</p> Signup and view all the answers

Which of the following IV solutions would be most appropriate for initially treating a patient with severe dehydration and hypotension?

<p>0.9% sodium chloride (NS) (C)</p> Signup and view all the answers

An older adult patient is receiving IV therapy. What strategies should the nurse implement to address potential cognitive changes related to the procedure?

<p>Speaking slowly and clearly and ensure the patient understands the procedure (A)</p> Signup and view all the answers

A patient is experiencing metabolic alkalosis. Which of the following clinical manifestations would the nurse expect?

<p>Hyperactive reflexes and tetany (D)</p> Signup and view all the answers

The nurse is caring for a patient with hyperkalemia. Which of the following interventions should be implemented first?

<p>Initiating continuous ECG monitoring (B)</p> Signup and view all the answers

The nurse is preparing to insert an IV catheter in an older adult. Which site should the nurse avoid?

<p>Lower extremities (C)</p> Signup and view all the answers

A patient is experiencing respiratory acidosis secondary to hypoventilation. Which intervention is most important?

<p>Improving airway and breathing (D)</p> Signup and view all the answers

The nurse is caring for a patient with fluid volume deficit. Which finding requires the most immediate attention?

<p>Confusion (D)</p> Signup and view all the answers

A patient has a prescription for a medication known to be a vesicant via peripheral IV. What action is essential for the nurse to implement?

<p>Frequent monitoring of the IV site for signs of extravasation (A)</p> Signup and view all the answers

An infant presents to the emergency department with signs of dehydration. Which assessment finding is most indicative of dehydration in this age group?

<p>Sunken fontanelles (C)</p> Signup and view all the answers

A construction worker is brought to the emergency department during the summer. He is sweating profusely. The nurse recognizes that this client is at risk for which of the following?

<p>Dehydration (B)</p> Signup and view all the answers

The nurse is reviewing a patient’s medication list and notices they are taking a thiazide diuretic. The nurse should monitor the patient for which of the following electrolyte imbalances?

<p>Hypokalemia (B)</p> Signup and view all the answers

A nurse is caring for a patient with a serum calcium level of 7.9 mg/dL. Which nursing intervention is most important?

<p>Monitoring for signs of tetany or muscle spasms (B)</p> Signup and view all the answers

A nurse is preparing to administer a dose of intravenous potassium chloride (KCl). Which action should the nurse prioritize to ensure patient safety?

<p>Diluting the KCl (D)</p> Signup and view all the answers

Which of the following represents the normal range for arterial blood pH?

<p>7.35 - 7.45 (C)</p> Signup and view all the answers

A patient with chronic obstructive pulmonary disease (COPD) is likely to develop which acid-base imbalance?

<p>Respiratory acidosis (C)</p> Signup and view all the answers

During the insertion of an intravenous catheter, the nurse notes blood return in the catheter, advances the catheter, and then attempts to flush the IV, but meets resistance. Which of the following the most appropriate next step?

<p>Remove the catheter and restart in a different location (D)</p> Signup and view all the answers

A patient who is experiencing a panic attack may exhibit which acid-base imbalance?

<p>Respiratory alkalosis (D)</p> Signup and view all the answers

Which electrolyte imbalance is most closely associated with ECG changes such as flattened T waves and the presence of U waves?

<p>Hypokalemia (B)</p> Signup and view all the answers

The nurse is caring for a patient with cirrhosis who has developed ascites. Which of the following pathophysiological mechanisms contributes to this condition?

<p>Excess fluid accumulates in the abdominal cavity, causing swelling (A)</p> Signup and view all the answers

What physiological process is primarily regulated by aldosterone?

<p>Sodium reabsorption in the collecting duct of nephrons (D)</p> Signup and view all the answers

Which of the following mechanisms causes cells in the brain and nervous system to swell in a patient with hyponatremia?

<p>Water moves from the ECF into the ICF (A)</p> Signup and view all the answers

Flashcards

Dehydration

Lack of fluid in the body from insufficient intake or excessive loss.

Hypovolemia

Also known as isotonic dehydration, lack of water and electrolytes causing a decrease in circulating blood volume.

Fluid Volume Excess (FVE)

Manifests as an excess of fluid in the body

Metabolic Acidosis

Results from blood in the body being too acidic, with an HCO3- less than 22 and a pH less than 7.35

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Metabolic Alkalosis

Results from blood in the body being too alkaline, with an HCO3- greater than 26 and a pH greater than 7.45

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Respiratory Acidosis

A buildup of carbon dioxide in the lungs and the body fluids, which results in a PaCO2 greater than 45 and a pH less than 7.35

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Respiratory Alkalosis

Low carbon dioxide levels in the body, with a PaCO2 less than 35 and a pH greater than 7.45

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Infiltration (IV)

Occurs when non-vesicant IV fluids or medications leak into the surrounding tissue.

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Extravasation

Occurs when vesicant fluids or medications leak into the surrounding tissue from the IV site

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Phlebitis

Inflammation of the vein

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Potassium (K+) Range

Normal range: 3.5 to 5 mEq/L. It's vital for nerve and muscle function.

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Sodium (Na+) Range

Normal range: 136 to 145 mEq/L. Important in fluid balance and nerve transmission.

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Calcium (Ca+) Range

Normal range: 9 to 10.5 mg/dL. Essential for bone health, nerve and muscle function, and blood clotting.

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Magnesium (Mg2+) Range

Normal range: 1.3 to 2.1 mEq/L. It plays a role in muscle and nerve function, blood sugar control, and blood pressure regulation.

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Vital Signs in Dehydration

Hypothermia or hyperthermia, tachycardia, thready pulse, hypotension, tachypnea and hypoxia

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Neuromusculoskeletal signs of Dehydration

Dizziness, confusion, weakness, fatigue; seizures can occur in rapid/severe cases

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GI signs of Dehydration:

Thirst, dry mucous membranes, dry furrowed tongue, nausea, vomiting, anorexia, acute weight loss

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Other signs of Dehydration

Diminished capillary refill, cool clammy skin, sunken eyeballs, flattened neck veins, absence of tears, decreased skin turgor

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Vital signs in Fluid Volume Excess

Tachycardia, bounding pulse, hypertension, tachypnea and increased central venous pressure

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Neuromusculoskeletal signs of Hypervolemia

Confusion, muscle weakness, altered level of consciousness, paresthesia, visual changes, seizures (if severe, sudden hyponatremia/water excess).

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GI signs of Hypervolemia

Increased motility and ascites

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Respiratory signs of Fluid Volume Excess

Dyspnea and orthopnea

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Other signs of Fluid Volume Excess

Pitting edema, distended neck veins, weight gain, skin pallor and cool to touch

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Hyperkalemia

Blood potassium level greater than 5.0 mEq/L.

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Hyponatremia

Blood sodium level less than 136 mEq/L

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Hypernatremia

Blood sodium levels greater than 145 mEq/L

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Diet recommendations for Hypokalemia

Eat foods high in potassium

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Diet recommendations for Hyperkalemia

Decrease dietary consumption.

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Diet recommendations for Hypernatremia

Lower sodium by decreasing foods high in sodium

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Diet recommendations for Hypocalcemia

Eat foods to raise calcium levels

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Normal Blood pH

pH: 7.35 – 7.45

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Normal CO2 Range

35 - 45

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Normal HCO3 Range

22 – 26

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Nursing interventions for Dehydration

Encourage use of the call light and ask for assistance

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Nursing interventions for Fluid Volume Excess

Administer supplemental oxygen as needed and reduce IV flow rates

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IV placement

Place the tourniquet 10 – 15 cm (4-6 inches) above the selected site.

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Phlebitis signs and symptoms

Red streaks may be visible at the surface of the skin and consistent with the location of inflammation of the vein(s)

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IV therapy Considerations for Older Adults

Monitor fluid intake closely and encourage regular hydration

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Sodium regulation

Aldosterone increases Na+ reabsorption in the collecting duct of nephrons

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Calcium and Phosphate Relationship

Increasing serum calcium levels decreases phosphate levels; decreasing serum calcium increases phosphate

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Study Notes

Fluid and Electrolyte Ranges

  • Potassium (K+): Normal range is 3.5 to 5 mEq/L.
  • Sodium (Na+): Normal range is 136 to 145 mEq/L.
  • Calcium (Ca+): Normal range is 9 to 10.5 mg/dL.
  • Magnesium (Mg2+): Normal range is 1.3 to 2.1 mEq/L.

Dehydration/Hypovolemia

  • Vital signs may include hypothermia or hyperthermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, and hypoxia.
  • Neuromusculoskeletal symptoms may include dizziness, syncope, confusion, weakness, fatigue, and seizures (rapid/severe dehydration).
  • Gastrointestinal symptoms may include thirst, dry mucous membranes, dry furrowed tongue, nausea, vomiting, anorexia, and acute weight loss.
  • Renal symptoms include oliguria.
  • Other findings may include diminished capillary refill, cool, clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, absence of tears, and decreased skin turgor.

Fluid Volume Excess (FVE)/Hypervolemia

  • Vital signs may include tachycardia, bounding pulse, hypertension, tachypnea, and increased central venous pressure.
  • Neuromusculoskeletal symptoms may include confusion, muscle weakness, altered level of consciousness, paresthesia, visual changes, and seizures.
  • Gastrointestinal symptoms may include increased motility and ascites.
  • Respiratory symptoms may include dyspnea, orthopnea, and crackles.
  • Other findings may include pitting edema, distended neck veins, weight gain, and skin pallor and cool to the touch.

Nursing Care for Dehydration

  • Initiate and maintain IV access.
  • Provide oral and IV rehydration therapy as prescribed.
  • Monitor I&O and encourage fluids as tolerated and alert the provider if urine output is less than 30 mL/hr.
  • Monitor level of consciousness and gait stability.
  • Encourage using the call light and ask for assistance.
  • Advise to change positions slowly.

Nursing Care for Fluid Volume Excess

  • Implement prescribed restrictions for fluid and sodium intake.
  • Administer supplemental oxygen as needed and reduce IV flow rates.
  • Administer diuretics (osmotic and loop) as prescribed.
  • Reposition every two hours.
  • Support arms and legs to decrease dependent edema.

Hyponatremia Additional Info

  • Results from an excess of water in the plasma or loss of sodium-rich fluids.
  • Hyponatremia delays and slows the depolarization of membranes.
  • Water moves from the Extracellular fluid (ECF) into the Intracellular fluid (ICF), which causes cells in the brain and nervous system to swell.
  • Physical assessment varies.
  • Vital signs may also include hypothermia.

Hypernatremia Additional Info

  • Can cause significant neurologic, endocrine, and cardiac disturbances due to blood hypertonicity, causing a shift of water out of cells, leading to dehydration.

Hypokalemia Additional Info

  • Irregular pulse weak
  • Potassium level less than 3.5 mEq/L.

Hyperkalemia Additional Info

  • Potassium level greater than 5.0 mEq/L.
  • Increased potassium intake, potassium movement out of the cells, or inadequate renal excretion.
  • Potentially life-threatening.

Metabolic Acidosis - Causes and Interventions

  • HCO3 is low [<22]

  • The kidneys are too acidic

  • Excess acid production:

    • Lactic acid
    • Keto acids in Diabetic Ketoacidosis (DKA)
    • Exogenous ingestion (aspirin, ethylene glycol)
  • Impaired renal excretion

  • Hyperkalemia Symptoms: ECG monitoring, Tall Tented T waves

  • Kussmaul respiration and diarrhea

  • Lungs respond by increasing respirations, blowing off CO2 to become more base

  • Treat underlying condition, monitor labs, replace fluids and electrolytes, sodium bicarbonate

Metabolic Alkalosis Info

  • HCO3 is HIGH (>26)

  • Kidneys have too much base or loss of acid

  • Causes:

    • Large amounts of GI loss or vomitting
    • Chronic OTC antacids, ingesting bicarbonate
    • Thiazide Diuretics
    • Excreting hydrogen in urine -No real symptoms or feeling unwell, due to underlying causes (i.e. vomitting)
    • Lungs will respond by breathing slower, holding on to CO2 for blood to become more acidic
    • Give antiemetics, avoid diuretics

Respiratory Acidosis Info

  • PaCO2 is HIGH (>45)

  • Hypoventilation

  • Causes:

    • Increased CO2 in the blood through increased CO2 or respiratory depression
    • Obesity hypoventilation, COPD, emphysema
  • Symptoms:

    • Hypoxia (confusion, lethargy, drowsy, headache)
    • Decreased pH
    • Kidneys secrete H+ into urine and reabsorb the HCO3 into blood
    • Interventions: Treat the underlying conditions, improve airway/breathing, raise HOB, suctioning, O2

Respiratory Alkalosis Info

  • PaCO2 is Low (<35)

  • Hyperventialtion

  • Causes:

    • Decreased CO2 in the blood, lack of acid through:
    • Anxiety panic, fever, high altitude, improper ventilation settings
  • Patients show:

    • Lightheadedness, dizziness, confusion, tachycardia, calcium imbalances
    • Increased pH where Kidneys reabsorb H+
  • Interventions:

    • Treat underlying conditions, improve airway
  • Foods with high potassium; eat foods high in potassium like baked potato, prune juice, carrot juice, white beans, plain yogurt, sweet potatoes, salmon, banana, spinach, and avocado
  • Decrease dietary intake of sodium through like roasted ham, shrimp, frozen pizza, canned soup, vegetable juice, cottage cheese, instant vanilla puddin, regular vanilla puddin

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