Chapter 13: Fluid & Electrolyte & Imbalance Flashcards
Hypoalbuminemia results in which clinical finding?
Edema .
because low levels of albumin (protein) reduce osmotic pressure, leading to fluid leakage from blood vessels into surrounding tissue causing swelling.
insensible fluid loss
example: respiration during breathing.
fluid loss that cannot be seen or measure with the naked eye.
ADH purpose is to____
ADH is released by the Pituitary Gland in respond to dehydration (to hold on to fluids).
Aldosterone causes:
- Retention of sodium
- Retention of water
- Excretion of potassium.
Aldosterone is produced by Adrenal cortex.
Which cardiovascular change would the nurse expect to find in a
patient with fluid overload?
Flat jugular veins
Increased heart rate
Widened pulse pressure
Decreased blood pressure
Increased HR
Type of patients at risk for fluid overload
- kidney disease
- heart failure
- liver disease
Which parameter in the laboratory results would indicate internal hemorrhage as a reason for dehydration in a patient brought to the emergency department in an unconscious state?
-Increased osmolarity
-Absence of hemoconcentration
-Elevated levels of blood components
-Decreased hemoglobin level
Absence of hemoconcentration.
Because hemoconcentration is not present when dehydration is caused by
hemorrhage because loss of all blood and plasma products occurs together.
Which assessment finding indicates that a patient is
dehydrated? Select all that apply. One, some, or all responses
may be correct.
-Fever
-Hypertension
-Poor skin turgor
-Pulmonary crackles
-Low blood pressure
-Concentrated urine
fever
poor skin turgor
low BP
concentrated urine
Which factor would the nurse consider when assessing a
patient’s fluid balance? Select all that apply. One, some, or all
responses may be correct.
-Age
-Height
-Sex
-Body fat
-Cholesterol
age
sex
body fat
Which change in patient assessment over 2 days reflects that the
administered diuretic is effective?
weight loss and increased urine output
Which item will the nurse include when documenting a patient’s
fluid intake?
( any measureable intake).
enema, oral fluids and irrigation fluids
When concerned about a patient’s GI fluid losses, which parameter would the nurse assess to determine fluid loss?
Select all that apply.
Weight
Skin turgor
Urine output
Blood pressure
Blood urea nitrogen (BUN)
ALL are correct
Which sign would the nurse expect to find when assessing a
patient with fluid overload? Select all that apply.
Weight gain
Hypotension
Crackles in the lungs
Weak peripheral pulses
Pitting edema in the ankles and feet
weight gain
crackles in the lungs
pitting edema in ankle/ feet
Which condition would the nurse suspect for a patient has dry
skin, a heart rate of 115 beats/min, a respiratory rate of 28
breaths/min, and weight loss of 1 lb in 1 day?
Dehydration
Hyperkalemia
Fluid overload
Hyponatremia
dehydration
Which assessment finding in a 78-year-old patient with severe
diarrhea indicates that the patient may be dehydrated? Select all
that apply.
Distended neck veins
Bounding radial pulses
Temperature of 99.4°F (37.4C)
Dizziness when standing
Newly reported confusion
temperature of 99.4.
dizziness when standing.
newly reported confusion.
Low-grade fever is a common result of dehydration. Postural hypotension
causing dizziness may occur with dehydration. Because of decreased
perfusion to the brain, confusion is common in older adults. With
dehydration, neck veins are flat, not distended; peripheral pulses are weak, not bounding.
The nurse calculates the amount of body fluid the patient has lost
when the patient temperature has risen 2C from normal. Record
________ mL
1000 Ml.
When a patient’s temperature is above normal (98.6°F [37C]), the body will
lose 500 mL for every degree Celsius the temperature has risen. Therefore a
patient with a temperature 2C over normal would have lost 1000 mL of body
fluid.
Which intervention would the nurse include in caring for a patient
with generalized edema who is receiving a loop diuretic?
Encouraging oral fluids
Restricting dietary potassium
Applying antiembolic stockings
Turning the patient every 2 hours
Turn the patient every 2 hours.
The patient with generalized edema/fluid overload is at risk for developing
skin breakdown, especially at pressure points over bony prominences.
Changing position frequently reduces this risk. Fluids are more likely to be
restricted with fluid overload, not encouraged. Loop diuretics cause
potassium loss, so dietary potassium is encouraged, not restricted.
Antiembolic stockings have no role in generalized edema from fluid overload.
Which goal would the health team set for a 77-year-old woman
brought to the emergency department with a history diarrhea
for 3 days, not eating or drinking well, taking diuretics for
congestive heart failure, and having a potassium level of 7.0
mEq/L?
Maintaining proper diuresis and urine output
Elevating serum potassium levels to a safe range
Decreasing cardiac contractility and slowing the heart rate
Restoring fluid balance by controlling causes of dehydration
Restoring fluid balance by controlling causes of dehydration
Which intervention would the nurse include in the plan of care
for a patient with pitting edema of the right foot and ankle who
is prescribed diuretic therapy? Select all that apply.
Monitoring respiratory rate
Monitoring urine output
Assessing sodium and potassium values
Checking urine for specific gravity
Monitoring electrocardiogram (ECG) patterns
monitor urine output.
asesss Na and K values.
monitor ECG patterns.
Patients with fluid overload often have pitting edema, and diuretic therapy
focuses on removing the excess fluid. The nursing interventions would be
monitoring the patient’s response to drug therapy, especially increased urine
output and weight loss. Diuretic therapy is associated with electrolyte
imbalance; therefore sodium and potassium levels need to be monitored.
Severe electrolyte disturbances may result in arrhythmias. Therefore changes
in the ECG should be monitored. Diuretic therapy does not cause respiratory
depression or changes in respiratory rate, so the respiratory rate does not need to be monitored. Checking the urine specific gravity is beneficial in
patients to detect fluid overload. However it is not useful in patients on
diuretic therapy.
Which finding for a 70-year-old patient admitted to the unit with
severe dehydration requires immediate intervention by the nurse?
Deep furrows on the surface of the tongue
Urine output of 950 mL for the past 24 hours
Behavior that changes from anxious to lethargic and confused
Poor skin turgor with tenting for 2 minutes after the skin is pinched
Behavior changes from anxious to lethargic and confused.
confusion is caused by poor cerebral flow, or shrinkage or swelling of brain cells caused by fluid shifts.
Which intervention would the nurse implement to maintain fluid
balance for a patient who is experiencing tachypnea?
Encourage oral fluids.
Administer IV fluids.
Establish fluid restrictions.
Administer the prescribed diuretic.
administer IV fluids.
Tachypnea can lead to increased fluid loss through insensible losses (e.g., from rapid breathing) and may cause dehydration. IV fluids can help rapidly restore fluid balance
Which patient on a medical-surgical unit is at an increased risk
for insensible water loss?
A patient receiving humidified oxygen by nasal cannula
A patient receiving continuous gastrointestinal (GI) suctioning
postoperatively
A patient with decreased respirations because of opioid
administration for pain
A patient receiving continuous IV fluids after surgery
A patient receiving continuous gastrointestinal (GI) suctioning
postoperatively.
Which parameter would lead to a recommendation for fluid
replacement therapy for a dehydrated patient?
Urine output of 550 mL per day
Heart rate of 100 beats/min
Respiratory rate of 18 breaths/min
Body temperature of 104°F (40C) for more than 8 hours
Body temperature of 104°F (40C) for more than 8 hours.
because a really high temperature can cause dehydration.
Which intervention would the nurse plan for the patient who is
receiving IV fluid replacement therapy and has a bounding
pulse, difficulty breathing, and distended neck veins in the
upright position?
Monitoring for weight changes
Administering diuretic drug therapy
Increasing fluid replacement therapy
Continuing fluid replacement therapy
Administering diuretic drug therapy
Which assessment finding is likely in a patient who is brought to
the emergency department reporting diarrhea and vomiting with
an elevated body temperature of 103°F (39.4C) for 2 days?
Urine output of 350 mL/day
Dry oral mucosal membranes
Respiratory rate of 22 breaths/min
Neck veins distended in supine position
Urine output of 350 mL/day.
Normal urine output should be 500 ml/day or more.
Which finding would indicate that a patient admitted with fluid
overload may have been prescribed a diuretic that is overly
effective? Select all that apply.
Report of fatigue
Weight loss of 9 lb
Heart rate increase from 70 to 96 beats/min
Heart rate decrease from 80 to 72 beats/min
Respiratory rate decrease from 20 to 16 breaths/min
Report of light-headedness when first standing up
Report of fatigue
Weight loss of 9 lb
Heart rate increase from 70 to 96 beats/min
Report of light-headedness when first standing up
Which condition may contribute to a patient’s insensible water
loss? Select all that apply.
Severe diarrhea
Respiratory rate of 36 breaths/min
Hot, dry home environment
Body temperature of 96.4°F (36C)
Large volume of urinary output
Severe diarrhea.
Respiratory rate of 36 breaths/min.
hot dry home environment.
For which additional electrolyte imbalance would the nurse
monitor in a patient who has hypomagnesemia?
Hyperkalemia
Hypocalcemia
Hypernatremia
Hypophosphatemia
Hypocalcemia.
hypocalcemia often occurs with hypomagnesemia, so you need to monitor s/sx of low calcium levels .
Positive Trousseau and Chvostek signs are consistent with which
electrolyte imbalance?
Hypokalemia
Hyperkalemia
Hypocalcemia
Hypercalcemia
Hypocalcemia.
due to overstimulation of nerves and muscles
Which patient is at high risk for hypernatremia?
30-year-old on a low-salt diet
42-year-old receiving hypotonic fluids
54-year-old who is on corticosteroids
17-year-old with a serum blood glucose level of 189 mg/dL
54-year-old who is on corticosteroids.
because corticosteroids can cause hypernatremia due to sodium retention and increase electrolyte free water loss.
When a patient reports disturbed deep sleep because of
frequent cramping in the calves, which electrolyte would the
nurse review in the patient’s health record?
Sodium
Calcium
Potassium
Magnesium
Calcium.
low calcium can cause muscle spasms, charley horse leg.
When analysis of a patient’s telemetry strip reveals a widened QRS
complex with peaked T waves, which laboratory value would the
nurse review before notifying the health care provider?
Sodium
Calcium
Potassium
Magnesium
Potassium.
hyperkalemia can cause cardiovascular changes including peaked T waves and widened QRS complex.
normal calcium level
9.0 to 10.5
normal magnesium level
1.5 to 2.5
Which intervention would the nurse expect to be prescribed for a
patient with hyponatremia?
2-g sodium diet
Administration of furosemide
IV administration of 0.45% normal saline
Small-volume IV infusions of 3% normal saline
Small-volume IV infusions of 3% normal saline.
3% saline is hypertonic and is given in small volumes to replenish serum sodium.
recommended IV infusion rate of Potassium for severe hypokalemia.
5 - 10 meq/ hour via IV
Which body system is especially affected by hyponatremia?
Cerebral
Endocrine
Respiratory
Cardiovascular
Neuromuscular
Cerebral
Cardiovascular
Neuromuscular
Which assessment finding would the nurse expect in the patient
diagnosed with hypokalemia? Select all that apply. One, some,
or all responses may be correct.
Paresthesia
Bradycardia
Shallow respirations
Weak, thready pulse
Muscle weakness
shallow respirations.
weak thready pulse.
Muscle weakness.
Which electrolyte deficiency would the nurse expect to find when
reviewing the laboratory data for a patient who presents with
seizure activity, decreased deep tendon reflexes, and diarrhea?
Sodium
Calcium
Potassium
Magnesium
Sodium.
hyponatremia can cause status changes, lethargy and seizure. it can also cause deep tendon reflex and diarrhea.
Which action would the nurse implement first for a patient who is
admitted with a serum potassium (K) level of 6.9 mEq/L?
Place the patient on a cardiac monitor.
Administer sodium polystyrene sulfonate orally.
Ensure that a potassium-restricted diet is prescribed.
Teach the patient about foods that are high in potassium.
Place the patient on a cardiac monitor.
Because hyperkalemia can lead to life threatening bradycardia, the initial action is to place patient on a cardiac monitor.
which (other and unpopular) loop diuretic can cause potassium loss?
Bumetanide
Which electrolyte imbalance would the nurse anticipate for a
patient who is admitted with fluid volume overload? Select all
that apply.
Hypokalemia
Hyponatremia
Hypercalcemia
Hypochloremia
Hypermagnesemia
Hypokalemia
Hyponatremia
Hypochloremia
Which assessment would the nurse complete first on the patient
admitted with hypokalemia?
Auscultating bowel sounds
Obtaining a pulse oximetry reading
Checking deep tendon reflexes (DTRs)
Determining the level of consciousness (LOC)
Obtaining a pulse oximetry reading.
because hypokalemia can cause respiratory difficulties.
hypocalcemia often occurs with hypo_____.
hypomagnesemia.
What calcium does to the body
- Nerve excitability
- Muscle contraction
- Clotting
- Builds bone density
Normal phosphate level
1.7- 2.6
Which assessment would the nurse perform first for a patient admitted with hypokalemia and skeletal muscle weakness?
Pulse
Respirations
Temperature
Blood pressure
Respirations.
Hypokalemia can lead to respiratory muscle weakness, which may result in shallow or ineffective breathing.
S/SX of Hyperkalemia
ptassium level is above 5.0.
symptoms include: diarrhea, chest discomfort, paresthesia, and the ECG changes (missed P waves, tall T waves, prolonged PR intervals, and wide QRS complexes)
which intervention should be done first with a patient that has hyponatremia?
assess respiratory status
SIADH
(Syndrome of inappropriate antidiuretic hormone).
Patient with SIADH will have fluid overload because of increased antidiuretic hormone.
Hypomagnesemia (low magnesium).
Normal magnesium 1.5 - 2.5
Cause: alcoholism, PPIs, high glucose levels
Symptoms: (magnesium acts like a sedative esp in muscles). So hypo mag means increase in energy.
Increase in:
• neuro excitability
• tremors
• deep tendon reflex
• BP & HR
• GI motility
• risk for seizure
Treatments:
• IV magnesium sulfate - give slowly
• eat more leafy greens, seeds, nuts
***place on SEIZURE PRECAUTION
Hypermagnesemia (high magnesium)
Follows calcium
Normal range 1.5 - 2.5
Cause: DKA, use of antacids/ laxatives, kidney failure
Symptoms: (magnesium acts like a sedative, slows things down). prolong PR interval / widened QRS due to slowed heart.
Decrease in:
• BP & HR
• LOC & energy
• RR & shallow (bradypnea)
• bowel sounds due to decreased GI motility
• muscle tone
• deep tendon reflex (DTR)
Treatments:
• IV calcium gluconate (this is the antidote for mag toxicity)
• loop diuretics
• dialysis
Hypercalcemia ( high calcium)
Follows magnesium
Normal calcium level 9.0 - 10.5
Cause: hyperactive parathyroid, antacids, cancer cells that release excess calcium into body.
Symptoms: decreased BP, HR, RR.
Short QT, wide T waves.
Muscle weakness
Slow lungs/ GI
Kidney stones
Decreased DTR
Treatment:
• Loop diuretics (furosemide)
• give IV phosphate or Biphosphate (phosphate decreases Calcium).
• monitor EKG
• 0.9% saline IV to dilute blood serum
Hypocalcemia ( low calcium)
Normal level 9.0 - 10.5
Cause: decreased parathyroid, corticosteroids, loop diuretics (furosemide) , low magnesium levels (coz ca/mag are BFFs), increased in phosphate levels
Symptoms: decrease blood clotting ,
V Tach due to heart excitability,
Prolong QT interval.
Lung Spasms (dyspnea and crackles) ,
GI excitability (diarrhea) l,
positive TROUSSEAU (arm twerks) &
CHVOSTEK (cheek movement).
Treatment :
• IV calcium / Calcium Acetate
• antacids (tums) which contain calcium
• leafy greens, dairy, salmon
• FALL RISK / BLEEDING / cardiac dysrhythmias
AVOID: loop diuretics / phosphate products
