Podcast
Questions and Answers
A patient with dehydration is likely to exhibit which set of vital signs?
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?
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?
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?
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?
A patient is diagnosed with hyperkalemia. Which ECG finding is most concerning?
A patient is diagnosed with hyperkalemia. Which ECG finding is most concerning?
A nurse is educating a patient with hypokalemia about dietary sources of potassium. Which food should the nurse recommend?
A nurse is educating a patient with hypokalemia about dietary sources of potassium. Which food should the nurse recommend?
The nurse is assessing a patient with suspected hypocalcemia. Which assessment finding supports this diagnosis?
The nurse is assessing a patient with suspected hypocalcemia. Which assessment finding supports this diagnosis?
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?
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?
Which of the following IV solutions is most appropriate for a patient experiencing dehydration with hypotension?
Which of the following IV solutions is most appropriate for a patient experiencing dehydration with hypotension?
A nurse is caring for an elderly patient receiving intravenous fluid therapy. Which nursing consideration is most important to prevent fluid overload?
A nurse is caring for an elderly patient receiving intravenous fluid therapy. Which nursing consideration is most important to prevent fluid overload?
A patient with a serum sodium level of 150 mEq/L is most likely experiencing which of the following?
A patient with a serum sodium level of 150 mEq/L is most likely experiencing which of the following?
Which electrolyte imbalance is most likely to result from excessive vomiting or nasogastric suctioning?
Which electrolyte imbalance is most likely to result from excessive vomiting or nasogastric suctioning?
A patient is prescribed a diuretic that increases potassium excretion. Which electrolyte level should the nurse monitor most closely?
A patient is prescribed a diuretic that increases potassium excretion. Which electrolyte level should the nurse monitor most closely?
When evaluating fluid balance in a patient, which of the following intake and output (I&O) patterns should alert the nurse to potential dehydration?
When evaluating fluid balance in a patient, which of the following intake and output (I&O) patterns should alert the nurse to potential dehydration?
Which finding would the nurse expect to see in a patient experiencing hypercalcemia?
Which finding would the nurse expect to see in a patient experiencing hypercalcemia?
A patient with a history of heart failure is receiving intravenous normal saline at 150 mL/hr. Which assessment finding requires immediate nursing intervention?
A patient with a history of heart failure is receiving intravenous normal saline at 150 mL/hr. Which assessment finding requires immediate nursing intervention?
A patient with metabolic acidosis is likely to exhibit which respiratory pattern as a compensatory mechanism?
A patient with metabolic acidosis is likely to exhibit which respiratory pattern as a compensatory mechanism?
Which of the following nursing interventions is most appropriate for a patient experiencing respiratory alkalosis due to anxiety?
Which of the following nursing interventions is most appropriate for a patient experiencing respiratory alkalosis due to anxiety?
A patient receiving a blood transfusion develops burning pain and redness at the IV site. Which complication should the nurse suspect?
A patient receiving a blood transfusion develops burning pain and redness at the IV site. Which complication should the nurse suspect?
An older adult patient is receiving IV fluids. Which nursing action is most important to prevent complications related to the patient's cardiovascular system?
An older adult patient is receiving IV fluids. Which nursing action is most important to prevent complications related to the patient's cardiovascular system?
A patient is diagnosed with hypokalemia. Which assessment finding would the nurse correlate with this electrolyte imbalance?
A patient is diagnosed with hypokalemia. Which assessment finding would the nurse correlate with this electrolyte imbalance?
Which of the following food choices is most appropriate for a patient trying to increase their potassium intake?
Which of the following food choices is most appropriate for a patient trying to increase their potassium intake?
A dehydrated patient is prescribed an IV solution. Which of the following parameters indicates that the rehydration therapy is effective?
A dehydrated patient is prescribed an IV solution. Which of the following parameters indicates that the rehydration therapy is effective?
A patient with hypernatremia is being educated about dietary modifications. Which food should the patient limit?
A patient with hypernatremia is being educated about dietary modifications. Which food should the patient limit?
Which nursing intervention is most appropriate when administering IV fluids to an elderly patient to prevent fluid overload?
Which nursing intervention is most appropriate when administering IV fluids to an elderly patient to prevent fluid overload?
Which assessment finding in a patient post-thyroidectomy should prompt the nurse to suspect hypocalcemia?
Which assessment finding in a patient post-thyroidectomy should prompt the nurse to suspect hypocalcemia?
A patient with chronic kidney disease is at risk for developing which acid-base imbalance?
A patient with chronic kidney disease is at risk for developing which acid-base imbalance?
A patient is diagnosed with fluid volume overload. The nurse would expect to find which of the following vital sign changes?
A patient is diagnosed with fluid volume overload. The nurse would expect to find which of the following vital sign changes?
Which of the following IV solutions would be most appropriate for initially treating a patient with severe dehydration and hypotension?
Which of the following IV solutions would be most appropriate for initially treating a patient with severe dehydration and hypotension?
An older adult patient is receiving IV therapy. What strategies should the nurse implement to address potential cognitive changes related to the procedure?
An older adult patient is receiving IV therapy. What strategies should the nurse implement to address potential cognitive changes related to the procedure?
A patient is experiencing metabolic alkalosis. Which of the following clinical manifestations would the nurse expect?
A patient is experiencing metabolic alkalosis. Which of the following clinical manifestations would the nurse expect?
The nurse is caring for a patient with hyperkalemia. Which of the following interventions should be implemented first?
The nurse is caring for a patient with hyperkalemia. Which of the following interventions should be implemented first?
The nurse is preparing to insert an IV catheter in an older adult. Which site should the nurse avoid?
The nurse is preparing to insert an IV catheter in an older adult. Which site should the nurse avoid?
A patient is experiencing respiratory acidosis secondary to hypoventilation. Which intervention is most important?
A patient is experiencing respiratory acidosis secondary to hypoventilation. Which intervention is most important?
The nurse is caring for a patient with fluid volume deficit. Which finding requires the most immediate attention?
The nurse is caring for a patient with fluid volume deficit. Which finding requires the most immediate attention?
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?
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?
An infant presents to the emergency department with signs of dehydration. Which assessment finding is most indicative of dehydration in this age group?
An infant presents to the emergency department with signs of dehydration. Which assessment finding is most indicative of dehydration in this age group?
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?
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?
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?
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?
A nurse is caring for a patient with a serum calcium level of 7.9 mg/dL. Which nursing intervention is most important?
A nurse is caring for a patient with a serum calcium level of 7.9 mg/dL. Which nursing intervention is most important?
A nurse is preparing to administer a dose of intravenous potassium chloride (KCl). Which action should the nurse prioritize to ensure patient safety?
A nurse is preparing to administer a dose of intravenous potassium chloride (KCl). Which action should the nurse prioritize to ensure patient safety?
Which of the following represents the normal range for arterial blood pH?
Which of the following represents the normal range for arterial blood pH?
A patient with chronic obstructive pulmonary disease (COPD) is likely to develop which acid-base imbalance?
A patient with chronic obstructive pulmonary disease (COPD) is likely to develop which acid-base imbalance?
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?
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?
A patient who is experiencing a panic attack may exhibit which acid-base imbalance?
A patient who is experiencing a panic attack may exhibit which acid-base imbalance?
Which electrolyte imbalance is most closely associated with ECG changes such as flattened T waves and the presence of U waves?
Which electrolyte imbalance is most closely associated with ECG changes such as flattened T waves and the presence of U waves?
The nurse is caring for a patient with cirrhosis who has developed ascites. Which of the following pathophysiological mechanisms contributes to this condition?
The nurse is caring for a patient with cirrhosis who has developed ascites. Which of the following pathophysiological mechanisms contributes to this condition?
What physiological process is primarily regulated by aldosterone?
What physiological process is primarily regulated by aldosterone?
Which of the following mechanisms causes cells in the brain and nervous system to swell in a patient with hyponatremia?
Which of the following mechanisms causes cells in the brain and nervous system to swell in a patient with hyponatremia?
Flashcards
Dehydration
Dehydration
Lack of fluid in the body from insufficient intake or excessive loss.
Hypovolemia
Hypovolemia
Also known as isotonic dehydration, lack of water and electrolytes causing a decrease in circulating blood volume.
Fluid Volume Excess (FVE)
Fluid Volume Excess (FVE)
Manifests as an excess of fluid in the body
Metabolic Acidosis
Metabolic Acidosis
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Metabolic Alkalosis
Metabolic Alkalosis
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Respiratory Acidosis
Respiratory Acidosis
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Respiratory Alkalosis
Respiratory Alkalosis
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Infiltration (IV)
Infiltration (IV)
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Extravasation
Extravasation
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Phlebitis
Phlebitis
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Potassium (K+) Range
Potassium (K+) Range
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Sodium (Na+) Range
Sodium (Na+) Range
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Calcium (Ca+) Range
Calcium (Ca+) Range
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Magnesium (Mg2+) Range
Magnesium (Mg2+) Range
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Vital Signs in Dehydration
Vital Signs in Dehydration
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Neuromusculoskeletal signs of Dehydration
Neuromusculoskeletal signs of Dehydration
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GI signs of Dehydration:
GI signs of Dehydration:
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Other signs of Dehydration
Other signs of Dehydration
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Vital signs in Fluid Volume Excess
Vital signs in Fluid Volume Excess
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Neuromusculoskeletal signs of Hypervolemia
Neuromusculoskeletal signs of Hypervolemia
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GI signs of Hypervolemia
GI signs of Hypervolemia
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Respiratory signs of Fluid Volume Excess
Respiratory signs of Fluid Volume Excess
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Other signs of Fluid Volume Excess
Other signs of Fluid Volume Excess
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Hyperkalemia
Hyperkalemia
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Hyponatremia
Hyponatremia
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Hypernatremia
Hypernatremia
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Diet recommendations for Hypokalemia
Diet recommendations for Hypokalemia
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Diet recommendations for Hyperkalemia
Diet recommendations for Hyperkalemia
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Diet recommendations for Hypernatremia
Diet recommendations for Hypernatremia
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Diet recommendations for Hypocalcemia
Diet recommendations for Hypocalcemia
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Normal Blood pH
Normal Blood pH
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Normal CO2 Range
Normal CO2 Range
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Normal HCO3 Range
Normal HCO3 Range
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Nursing interventions for Dehydration
Nursing interventions for Dehydration
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Nursing interventions for Fluid Volume Excess
Nursing interventions for Fluid Volume Excess
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IV placement
IV placement
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Phlebitis signs and symptoms
Phlebitis signs and symptoms
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IV therapy Considerations for Older Adults
IV therapy Considerations for Older Adults
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Sodium regulation
Sodium regulation
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Calcium and Phosphate Relationship
Calcium and Phosphate Relationship
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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
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Kussmaul respiration and diarrhea
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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
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HCO3 is HIGH (>26)
-
Kidneys have too much base or loss of acid
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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
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PaCO2 is HIGH (>45)
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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
Recommended Foods for Electrolyte Imbalances
- 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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