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NURS 112 - TEST 5 - UNITS F.5 & (I) > CH 58 - ELECTROLYTE IMBALANCE > Flashcards

CH 58 - ELECTROLYTE IMBALANCE Flashcards

1
Q

CHAPTER 58

A

Electrolyte Imbalances

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2
Q

Electrolytes are

A

minerals (sometimes called salts) that have an electric charge and are present in all body fluids.

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3
Q

ELECTRPLYTES regulate

A

fluid balance /
hormone productioN /,
strengthen skeletal structures,
act as catalysts in nerve response,
muscle contraction,
the metabolism of nutrients.

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4
Q

Major electrolytes in the body include

A

sodium, potassium, chloride, magnesium, phosphorus, and calcium.

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5
Q

Electrolytes are either

A

POSITIVE OR NEGATIVE

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6
Q

positive ELECTROLYTES -

A

(cations: magnesium, potassium, sodium, calcium)

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7
Q

NEGATIVE ELECTROLYTES AKA

A

(anions: phosphate, sulfate, chloride, bicarbonate).

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8
Q

Monitoring laboratory values can help in identifying

A

any electrolyte imbalances.

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9
Q

While laboratory tests can accurately reflect the electrolyte concentrations in________, it is ____possible to directly measure electrolyte concentrations within _____

A

plasma
NOT
CELLS

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10
Q

Clients at greatest risk for electrolyte imbalance are

A

infants,
children,
older adults,
clients who have cognitive disorders, and
clients who have chronic illnesses.

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11
Q

EXPECTED REFERENCE RANGES Sodium:

A

136 to 145 mEq/L

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12
Q

EXPECTED REFERENCE RANGES Calcium:

A

9 to 10.5 mg/dL

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13
Q

EXPECTED REFERENCE RANGES Potassium:

A

3.5 to 5 mEq/L

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14
Q

EXPECTED REFERENCE RANGES Magnesium:

A

1.3 to 2.1 mEq/L

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15
Q

EXPECTED REFERENCE RANGES Chloride:

A

98 to 106 mEq/L

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16
Q

EXPECTED REFERENCE RANGES Phosphorus:

A

3 to 4.5 mg/Dl

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17
Q

Sodium (Na+) FOUND IN WHAT TISSUES

A

found in ECF and is present in most body fluids or secretions.

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18
Q

● Sodium is essential for

A

maintenance of acid‑base / fluid balance,
active / passive transport mechanisms,
irritability / conduction of nerve / muscle tissue.

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19
Q

● Hyponatremia is a blood sodium level less

A

than 136 mEq/L.

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20
Q

Hyponatremia results from

A

an excess of water in the plasma or loss of sodium‑rich fluids.

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21
Q

● Hyponatremia delays and slows the

A

depolarization of membranes.

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22
Q

IN HYPONATREMIA WATER MOVES IN WHAT DIRECTION

A

from the ECF into the ICF, which causes cells in the brain and nervous system to swell.

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23
Q

HYPO * NA * TREMIA

A

BELOW/UNDER * SODIUM * BLOOD

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24
Q

water moving from ECF to ICF causes what

A

causes cells in the brain and nervous system to swell.

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25
Q

RISK FACTORS - for Hyponatremia

A

Deficient ECF volume
● Excessive GI losses:
● Renal losses:
● Skin losses:
Increased or normal ECF volume: excessive oral water intake, syndrome of inappropriate antidiuretic hormone secretion (SIADH)
● Edematous states: heart failure, cirrhosis, nephrotic syndrome
● Excessive IV administration of dextrose 5% in water
● Inadequate sodium intake (NPO status)
● Use of hypotonic irrigating solutions
● Hyperglycemia
● Older adult clients are at greater risk due to an increased incidence of chronic illnesses, use of diuretic medications, and risk for insufficient sodium intake.

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26
Q

Deficient ECF volume can come from

A

excessive GI losses; renal losses; skin losses; increased or normal ECF; edematous state; excessive IV admin of dextrose in H20; hypotonic irrigations; hyperglycemia; older clients

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27
Q

● Excessive GI losses:

A

vomiting, nasogastric suctioning, diarrhea, tap water enemas

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28
Q

● Renal losses:

A

diuretics, kidney disease, adrenal insufficiency, excessive sweating

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29
Q

● Skin losses:

A

burns, wound

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30
Q

Increased or normal ECF volume:

A

excessive oral water intake, syndrome of inappropriate antidiuretic hormone secretion (SIADH)

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31
Q

● Edematous states:

A

heart failure, cirrhosis, nephrotic syndrome

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32
Q

● Excessive IV administration of

A

dextrose 5% in water

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33
Q

● Inadequate sodium intake

A

(NPO status)

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34
Q

● Older adult clients are at greater risk due to

A

an increased incidence of chronic illnesses, use of diuretic medications, and risk for insufficient sodium intake.

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35
Q

EXPECTED FINDINGS for hyponatremia

A

Vary with a normal, decreased, or increased ECF volume

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36
Q

VITAL SIGNS: - hyponatremia

A

Hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension

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37
Q

NEUROMUSCULOSKELETAL: - hyponatremia

A

Headache, confusion, lethargy, muscle weakness with possible respiratory compromise, fatigue, decreased deep tendon reflexes (DTRs), seizures, coma

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38
Q

GI: - hyponatremia

A

Increased motility, hyperactive

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39
Q

NURSING CARE - hyponatremia

A

● Monitor I&O / weigh client daily - same time o/ same scale.
● Monitor vital signs / level of consciousness, reporting irregular findings.
● Encourage to change positions slowly.
● Follow prescribed fluid restrictions.
● Monitor respiratory status if muscle weakness present.
● Encourage foods / fluids high in sodium (cheese, milk, condiments).

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40
Q

FLUID OVERLOAD do what?

A

● Restrict water intake as prescribed.

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41
Q

if fluid overload, restricting water intake is typically effective when

A

fluid volume is normal to high.

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42
Q

SEVERE HYPONATREMIA: Administer

A

hypertonic oral and IV fluids as prescribed.

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43
Q

Hypernatremia

A

●blood sodium level greater than 145 mEq/L.
● serious electrolyte imbalance.
It can cause significant neurologic, endocrine, and cardiac disturbances.
● Increased sodium causes hypertonicity of the blood. This causes a shift of water out of the cells, making the cells dehydrated.

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44
Q

Hypernatremia can cause

A

significant neurologic, endocrine, and cardiac disturbances.

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45
Q

Increased sodium causes

A

hypertonicity of the blood. This causes a shift of water out of the cells, making the cells dehydrated.

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46
Q

hypertonicity of the blood. This causes a

A

shift of water out of the cells, making the cells dehydrated.

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47
Q

risk factors for hypernatremia

A

● Water deprivation (NPO)
● Heat stroke
● Excessive sodium intake:
● Excessive sodium retention:
● Fluid losses:

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48
Q

hypernatremia

A

above/oversodiumblood

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49
Q

● Excessive sodium intake:

A

dietary sodium intake, hypertonic IV fluids, hypertonic tube feedings, bicarbonate intake

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50
Q

● Excessive sodium retention:

A

kidney failure, Cushing’s syndrome, aldosteronism, some medications (glucocorticosteroids)

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51
Q

● Fluid losses:

A

fever, diaphoresis, burns, respiratory infection, diabetes insipidus, hyperglycemia, watery diarrhea

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52
Q

EXPECTED FINDINGS - hypernatremia

A

VITAL SIGNS: Hyperthermia, tachycardia, orthostatic hypotension
NEUROMUSCULOSKELETAL: Restlessness, fatigue, disorientation, irritability, muscle twitching, muscle weakness, seizures, decreased level of consciousness, reduced to absent DTRs
GI: Thirst, dry and sticky mucous membranes, dry and swollen tongue that is red in color, increased motility, hyperactive bowel sounds, abdominal cramping, nausea
OTHER FINDINGS: Edema, warm flushed skin, oliguria

53
Q

VITAL SIGNS: - hypernatremia

A

Hyperthermia, tachycardia, orthostatic hypotension

54
Q

NEUROMUSCULOSKELETAL: - - hypernatremia

A

Restlessness, fatigue, disorientation, irritability, muscle twitching, muscle weakness, seizures, decreased level of consciousness, reduced to absent DTRs

55
Q

GI: - hypernatremia

A

Thirst, dry and sticky mucous membranes, dry and swollen tongue that is red in color, increased motility, hyperactive bowel sounds, abdominal cramping, nausea

56
Q

OTHER FINDINGS: - hypernatremia

A

Edema, warm flushed skin, oliguria

57
Q

NURSING CARE - hypernatremia

A

● Monitor level of consciousness / ensure safety.
● Provide oral hygiene / other comfort measures to decrease thirst.
● Monitor I&O / alert provider if urinary output inadequate.
● Maintain prescribed diet (low sodium, no added salt).
● Encourage oral fluids as prescribed.

58
Q

hypernatremia FLUID LOSS: Based on

A

blood osmolarity
Administer hypotonic or isotonic (non-sodium) IV fluids.

59
Q

hypernatremia EXCESS SODIUM

A

Encourage water intake and discourage sodium intake.
● Administer diuretics (loop diuretics) if impaired kidney excretion is the cause of hypernatremia.

60
Q

POTASSION major cation in

A

ICF.

61
Q

POTASSION ROLE IN

A

cell metabolism; transmission of nerve impulses; functioning of cardiac, lung, and muscle tissues; and acid‑base balance.

62
Q

POTASSION HAS RECIPROCAL ACTION W/

A

SODIUM

63
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) LEVEL <

A

3.5 mEq/L.

64
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) RESULT OF

A

increased loss of potassium from the body, decreased intake and absorption of potassium, or movement of potassium into the cells.

65
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) RISK FACTORS

A

● Hyperaldosteronism
● Inadequate dietary intake (rare)
● Prolonged administration of non‑electrolyte‑containing IV solutions (5% dextrose in water)
● Receiving total parenteral nutrition
● Metabolic alkalosis

66
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) EXCESSIVE GI LOSSES

A

EXCESSIVE GI LOSSES: Vomiting, nasogastric suctioning, diarrhea, excessive laxative use

67
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) RENAL LOSSES

A

RENAL LOSSES: Excessive use of potassium‑excreting diuretics (furosemide, corticosteroids)

68
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) SKIN LOSSES

A

SKIN LOSSES: Diaphoresis, wound losses

69
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) EXPECTED FINDINGS VITAL SIGNS

A

VITAL SIGNS: Weak, irregular pulse, hypotension, orthostatic hypotension, respiratory distress

70
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) EXPECTED FINDINGS NEUROMUSCULOSKJELTAL

A

NEUROMUSCULOSKELETAL: Ascending bilateral muscle weakness with respiratory collapse and paralysis, muscle cramping, decreased muscle tone and hypoactive reflexes, paresthesias, mental confusion

71
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) EXPECTED FINDINGS ELECTROCARDIOGRAM (ECG)

A

ELECTROCARDIOGRAM (ECG): Premature ventricular contractions (PVCs), bradycardia, blocks, ventricular tachycardia, flattening, flattened, or inverted T waves, increased U waves, and ST depression

72
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) EXPECTED FINDINGS GI:

A

GI: Decreased motility, hypoactive bowel sounds, abdominal distention, constipation, ileus, nausea, vomiting, anorexia

73
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) EXPECTED FINDINGS OTHER CLINICAL FINDINGS:

A

OTHER CLINICAL FINDINGS: Anxiety, which can progress to lethargy

74
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) NURSING CARE

A

● Treat the underlying cause.
● Replace potassium.
◯ Provide dietary education and encourage foods high in potassium (avocados, dried fruit, cantaloupe, bananas, potatoes, spinach).
◯ Provide oral potassium supplementation.
◯ IV potassium administration can be required; it should always be diluted and administered slowly by intermittent infusion.
! Never IV bolus (high risk of cardiac arrest).
● Monitor for and maintain an adequate urine output.
● Monitor for shallow, ineffective respirations and diminished breath sounds.
● Monitor cardiac rhythm and intervene promptly as needed.
● Monitor clients receiving digoxin. Hypokalemia increases the risk for digoxin toxicity.
● Monitor level of consciousness and ensure safety.
● Monitor bowel sounds and abdominal distention and intervene as needed.

75
Q

POTASSION (HYPOKALEMIA - NOT ENOUGH K+ IN BLOOD) NEVER DO THIS - HIGH RISK OF CARDIAC ARREST

A

! Never IV bolus (high risk of cardiac arrest).

76
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) LEVEL >

A

5.0 mEq/L.

77
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) RESULT OF

A

an increased intake of potassium, movement of potassium out of the cells, or inadequate renal excretion.

78
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) UNCOMMON IN CLIENTS WHO

A

clients who have adequate kidney function.

79
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) POTENTIALLY LIFE THREATENING DUE TO

A

the risk of cardiac arrhythmias and cardiac arrest.

80
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) RISK FACTORS

A

INCREASED TOTAL BODY POTASSIUM: IV potassium administration, salt substitutes, blood transfusion
ECF SHIFT: Insufficient insulin, acidosis (diabetic ketoacidosis), tissue catabolism (sepsis, burns, trauma, surgery, fever, myocardial infarction)
HYPERTONIC STATES: Uncontrolled diabetes mellitus
DECREASED EXCRETION OF POTASSIUM: Kidney failure, severe dehydration, potassium‑sparing diuretics, ACE inhibitors, adrenal insufficiency
AGE: Older adult clients at greater risk due to decreased kidney function and medical conditions resulting in the use of salt substitutes, angiotensin‑converting enzyme inhibitors, and potassium‑sparing diuretics

81
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) EXPECTED FINDINGS VITAL SIGNS

A

VITAL SIGNS: Slow, irregular pulse; hypotension

82
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) EXPECTED FINDINGS NEUROMUSCULOSKELETAL

A

NEUROMUSCULOSKELETAL: Irritability, confusion, weakness with ascending flaccid paralysis, paresthesias, lack of reflexes

83
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) EXPECTED FINDINGS GI

A

GI: Increased motility, diarrhea, abdominal cramps, hyperactive bowel sounds

84
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) DIAGNOSTIC PROCEDURE

A

ECG will show peaked T waves, widened PR and QRS.
Dysrhythmias and asystole are possible.

85
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) NURSING CARE

A

● Implement continuous ECG monitoring.
● Decrease potassium intake.
◯ Stop infusion of IV potassium.
◯ Withhold oral potassium.
◯ Provide a potassium‑restricted diet.
● If potassium levels are extremely high, dialysis might be required.
● Administer IV fluids with dextrose and regular insulin as prescribed to promote the movement of potassium from the ECF to the ICF. Follow agency protocol.
● Monitor cardiac rhythm and intervene promptly as needed.
● Maintain IV access.
● Prepare the client for dialysis if prescribed.
● Administer sodium polystyrene sulfonate as prescribed.

86
Q

POTASSION (HYPERKALEMIA - TO MUCH K+ IN BLOOD) MEDICATIONS TO INCREASE K+ EXCRETION

A

● Administer loop diuretics (furosemide) if kidney function is adequate. Loop diuretics increase the excretion of potassium from the renal system.
● Sodium polystyrene sulfonate is given orally or as an enema. Sodium polystyrene sulfonate increases the excretion of potassium from the gastrointestinal system.
● Other medications can include calcium gluconate, albuterol, and patiromer.

87
Q

CALCIUM FOUND IN

A

body’s cells, bones, and teeth.

88
Q

CALCIUM ESSENTIAL FOR

A

● Calcium balance is essential for proper functioning of the cardiovascular, neuromuscular, and endocrine systems, as well as blood clotting and bone and teeth formation.

89
Q

CALCIUM (HYPOCALCEMIA- TO LITTLE CALCIUM IN BLOOD) TOTAL BLOOD CALCIUM LEVEL <

A

9 mg/dL.

90
Q

CALCIUM (HYPOCALCEMIA- TO LITTLE CALCIUM IN BLOOD) RISK FACTORS - INCREASED CALCIUM OUTPUT

A

● Chronic diarrhea
● Laxative misuse
● Steatorrhea as with pancreatitis (binding of calcium to undigested fat)

91
Q

CALCIUM (HYPOCALCEMIA- TO LITTLE CALCIUM IN BLOOD) INADEQUATE CALCIUM INTAKE OR ABSORPTION

A

● Malabsorption syndromes (Crohn’s disease)
● Vitamin D deficiency (alcohol use disorder, chronic kidney disease)

92
Q

CALCIUM (HYPOCALCEMIA- TO LITTLE CALCIUM IN BLOOD) CALCIUM SHIFT FROM ECF INTO BONE OR INACTIVE FORM

A

● Rapid infusion of citrated blood transfusion
● Post‑thyroidectomy
● Hypoparathyroidism
● Hypoalbuminemia
● Alkalosis
● Pancreatitis
● Hyperphosphatemia

93
Q

CALCIUM (HYPOCALCEMIA- TO LITTLE CALCIUM IN BLOOD) EXPECTED FINDINGS MUSCLE TWITCHES / TETANY

A

● Numbness and tingling (fingers and around mouth)
● Frequent, painful muscle spasms at rest that can progress to tetany
● Hyperactive DTRs
● Positive Chvostek’s sign (tapping on the facial nerve triggering facial twitching)
● Positive Trousseau’s sign (hand/finger spasms w/ sustained blood pressure cuff inflation)
● Laryngospasms

94
Q

CALCIUM (HYPOCALCEMIA- TO LITTLE CALCIUM IN BLOOD) EXPECTED FINDINGS CARDIOVASCULAR

A

● Weak, thready pulse, tachycardia or bradycardia
● Cardiac dysrhythmias: prolonged QT interval and ST segments

95
Q

CALCIUM (HYPOCALCEMIA- TO LITTLE CALCIUM IN BLOOD) EXPECTED FINDINGS GI

A

Hyperactive bowel sounds, diarrhea, abdominal cramping

96
Q

CALCIUM (HYPOCALCEMIA- TO LITTLE CALCIUM IN BLOOD) EXPECTED FINDINGS CENTRAL NERVOUS SYSTEM (cns)

A

CENTRAL NERVOUS SYSTEM: Seizures due to overstimulation of the CNS

97
Q

CALCIUM (HYPERCALCEMIA- TO MUCH CALCIUM IN BLOOD) LEVEL >

A

10.5 mg/dL.

98
Q

CALCIUM (HYPERCALCEMIA- TO MUCH CALCIUM IN BLOOD) NOT AS COMMON AS

A

hypocalcemia.

99
Q

CALCIUM (HYPERCALCEMIA- TO MUCH CALCIUM IN BLOOD) CAUSES INCLUDE

A

thiazide diuretic or long term glucocorticoid use, Paget’s disease, hyperthyroidism and hyperparathyroidism, and bone cancer.

100
Q

CALCIUM (HYPERCALCEMIA- TO MUCH CALCIUM IN BLOOD) EXPECTED FINDINGS NEUROMUSCULAR

A

● Decreased reflexes
● Bone pain

101
Q

CALCIUM (HYPERCALCEMIA- TO MUCH CALCIUM IN BLOOD) EXPECTED FINDINGS CARDIOVASCULAR

A

● Dysrhythmias (shortened QT and ST intervals)
● Increased risk for blood clot

102
Q

CALCIUM (HYPERCALCEMIA- TO MUCH CALCIUM IN BLOOD) EXPECTED FINDINGS GI

A

Anorexia, nausea, vomiting, constipation

103
Q

CALCIUM (HYPERCALCEMIA- TO MUCH CALCIUM IN BLOOD) EXPECTED FINDINGS CENTRAL NERVOUS SYSTEM (CNS)

A

Weakness, lethargy
● Confusion, decreased level of consciousness
● Personality change

104
Q

CALCIUM (HYPERCALCEMIA- TO MUCH CALCIUM IN BLOOD) EXPECTED FINDINGS GI

A

Hypercalciuria

105
Q

CALCIUM (HYPERCALCEMIA- TO MUCH CALCIUM IN BLOOD) NURSING CARE

A

Treatment includes restricting calcium and increasing fluid intake.
● Monitor the client for pathological fractures.

106
Q

HYPOMAGNESEMIA (TO LITTLE MAGNESIUM IN BLOOD) BLOOD MAGNESIUM LEVEL <

A

lood magnesium level less than 1.3 mEq/L.

107
Q

HYPOMAGNESEMIA (TO LITTLE MAGNESIUM IN BLOOD) RISK FACTORS INCREASED MAGNESIUM OUTPUT GI

A

GI losses (diarrhea, nasogastric suction)
● Thiazide or loop diuretics
● Often associated with hypocalcemia

108
Q

HYPOMAGNESEMIA (TO LITTLE MAGNESIUM IN BLOOD) RISK FACTORS SHIFT INTO INACTIVE FORM

A

Rapid infusion of citrated blood

109
Q

HYPOMAGNESEMIA (TO LITTLE MAGNESIUM IN BLOOD) RISK FACTORS INADEQUATE MAGNESIUM INTAKE OR ABSORPTION

A

● Malnutrition
● Alcohol use disorder
● Laxative misuse

110
Q

HYPOMAGNESEMIA (TO LITTLE MAGNESIUM IN BLOOD) EXPECTED FINDINGS NEUROMUSCULAR

A

NEUROMUSCULAR: Increased nerve impulse transmission (hyperactive DTRs, paresthesias, muscle tetany), positive Chvostek’s and Trousseau’s signs, tetany, seizures, insomnia

111
Q

HYPOMAGNESEMIA (TO LITTLE MAGNESIUM IN BLOOD) EXPECTED FINDINGS GI

A

GI: Hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus

112
Q

HYPOMAGNESEMIA (TO LITTLE MAGNESIUM IN BLOOD) EXPECTED FINDINGS CARDIOVASCULAR

A

CARDIOVASCULAR: Dysrhythmias, tachycardia, hypertension, ECG waveform changes or PVCs

113
Q

HYPOMAGNESEMIA (TO LITTLE MAGNESIUM IN BLOOD) NURSING CARE

A

● Discontinue magnesium‑losing medications.
● Magnesium replacement can be required orally (if the client is experiencing mild manifestations) or IV (if manifestations are severe). Oral magnesium can cause diarrhea and increase magnesium depletion.
● Encourage foods high in magnesium, including whole grains and dark green vegetables.

114
Q

HYPERMAGNESEMIA (TO MUCH MAGNESIUM IN BLOOD) BLOOD MAGNESIUM LEVEL >

A

greater than 2.1 mEq/L.

115
Q

HYPERMAGNESEMIA (TO MUCH MAGNESIUM IN BLOOD) NOT AS COMMON AS

A

hypocalcemia.

116
Q

HYPERMAGNESEMIA (TO MUCH MAGNESIUM IN BLOOD) CAUSES INCLUDE

A

kidney or adrenal impairment and increased intake of medications containing magnesium (laxatives, antacids).

117
Q

HYPERMAGNESEMIA (TO MUCH MAGNESIUM IN BLOOD) EXPECTED FINDINGS NEUROMUSCULAR

A

● Diminished DTRs
● Muscle paralysis
● Shallow respirations, decreased respiratory rate

118
Q

HYPERMAGNESEMIA (TO MUCH MAGNESIUM IN BLOOD) EXPECTED FINDINGS CARDIOVASCULAR

A

● Bradycardia, hypotension
● Cardiac arrest
● Dysrhythmias, ECG changes (prolonged PR interval)

119
Q

HYPERMAGNESEMIA (TO MUCH MAGNESIUM IN BLOOD) EXPECTED FINDINGS CENTRAL NERVIOUS SYSTEM (CNS)

A

CENTRAL NERVOUS SYSTEM: Lethargy

120
Q

HYPERMAGNESEMIA (TO MUCH MAGNESIUM IN BLOOD) DIAGNOSTIC PROCEDUIRES

A

ECG: Prolonged PR interval, widened QRS

121
Q

HYPERMAGNESEMIA (TO MUCH MAGNESIUM IN BLOOD) NURSING CARE

A

● Perform frequent focused assessments (vital signs, level of consciousness, reflexes). Notify the provider of changes or absent reflexes.
● Administer loop diuretics and magnesium free IV fluids if kidney function is adequate.
● Administer calcium gluconate for severe cardiac changes.

122
Q
  1. A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?
    A. Infuse hypotonic IV fluids.
    B. Implement a fluid restriction.
    C. Increase sodium intake.
    D. Administer sodium polystyrene sulfonate.
A
  1. A. CORRECT: Hypotonic IV fluids are indicated for the treatment of hypernatremia related to fluid loss to expand the ECF volume and rehydrate the cells.
    B. Increased fluid intake is indicated for the treatment of hypernatremia.
    C. Decreased sodium intake is indicated for the treatment of hypernatremia.
    D. Administration of sodium polystyrene sulfonate is indicated for the treatment of hyperkalemia.
123
Q
  1. A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance?
    A. Crohn’s disease
    B. Postoperative following appendectomy
    C. History of bone cancer
    D. Hyperthyroidism
A
  1. A. CORRECT: Crohn’s disease is a risk factor for hypocalcemia. This malabsorption disorder places the client at risk for hypocalcemia due to inadequate calcium absorption.
    B. A thyroidectomy places the client at risk for hypocalcemia due to the possible removal of or injury to the parathyroid glands.
    C. A history of bone cancer increases the client’s risk of hypercalcemia due to the shift of calcium from bone to ECF.
    D. Hyperthyroidism places the client at risk for hypercalcemia due to the shift of calcium from bone to ECF.
124
Q
  1. A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions?
    A. Starting an IV infusion of 0.9% sodium chloride
    B. Consulting with dietitian to increase intake of potassium
    C. Initiating continuous cardiac monitoring
    D. Preparing the client for gastric lavage
A
  1. A. Initiate an IV infusion of a fluid containing dextrose to promote the movement of potassium from ECF to ICF.
    B. Withhold oral potassium and provide the client with a potassium‑restricted diet.
    C. CORRECT: A potassium level of 5.2 mEq/L indicates hyperkalemia. Anticipate the initiation of continuous cardiac monitoring due to the client’s
    risk for dysrhythmias (ventricular fibrillation).
    D. Gastric lavage is not indicated for the treatment of hyperkalemia. However, prepare the client for dialysis if hyperkalemia becomes severe.
125
Q
  1. A nurse is collecting data from a client who has hypercalcemia as a result of long‑term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply.)
    A. Hyperreflexia
    B. Confusion
    C. Positive Chvostek’s sign
    D. Bone pain
    E. Nausea and vomiting
A
  1. A. Expect the client who has hypercalcemia to have decreased reflexes.
    B. CORRECT: Expect the client who has hypercalcemia to have confusion and a possible decreased level of consciousness.
    C. Expect the client who has hypocalcemia to have a positive Chvostek’s sign.
    D. CORRECT: Expect the client who has hypercalcemia to have bone pain.
    E. CORRECT: Expect the client who has hypercalcemia to have nausea and vomiting along with anorexia.
126
Q
  1. A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching?
    A. “Avoid green, leafy vegetables while taking this medication.”
    B. “You should receive a prescription for a thiazide diuretic to take with the magnesium.”
    C. “You should eliminate whole grains from your diet until your magnesium level increases.”
    D. “Report diarrhea while taking this medication.”
A
  1. A. Green, leafy vegetables are rich in magnesium and do not hinder oral magnesium therapy.
    B. Thiazide diuretics increase magnesium output, thereby worsening the client’s hypomagnesemia.
    C. Encourage the client’s intake of foods that are high in magnesium (whole grains, nuts, cocoa).
    D. CORRECT: Instruct the client to report diarrhea while taking oral magnesium replacement. This is a potential adverse effect of taking oral magnesium, which could worsen the client’s hypomagnesemia.
127
Q

A nurse is caring for a client who has hypokalemia as an adverse effect of furosemide.
ALTERATION IN HEALTH (DIAGNOSIS)
EXPECTED FINDINGS: Identify at least five expected findings.

A

ALTERATION IN HEALTH (DIAGNOSIS): Hypokalemia is a blood potassium level less than 3.5 mEq/L that can result from the increased loss of potassium from the body due to the use of potassium‑excreting diuretics (furosemide).
EXPECTED FINDINGS
● Vital signs: Weak irregular pulse, hypotension, respiratory distress
● Neuromusculoskeletal: Ascending bilateral muscle weakness, muscle cramping, decreased muscle tone, hypoactive reflexes, paresthesias, mental confusion
● GI: Decreased motility, hypoactive bowel sounds, abdominal distention, constipation, nausea, vomiting, anorexia
● Dysrhythmias: PVCs, bradycardia, blocks, ventricular tachycardia, flattening T waves, ST depression

128
Q

NURSING CARE: Identify two nursing interventions for hypokalemia.

A

NURSING CARE
● Monitor for cardiac dysrhythmia.
● Monitor for shallow or ineffective respirations.
● Teach and encourage consumption of potassium rich foods (bananas, avocados, cantaloupe).
● Ensure the underlying cause of hypokalemia is corrected.

NURS 112 - TEST 5 - UNITS F.5 & (I) (9 decks)

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