EF - FLUID ELEC ACID BASE Flashcards
· acid–base balance
o The homeostasis of acidic and basic (alkaline) compounds in the blood to maintain a blood pH of between 7.35 and 7.45.
· acidosis
o Levels of acid in the blood are too high, a pH of less than 7.35.
· active transport
o The movement of electrolytes or molecules across a cell membrane with the use of energy in the form of enzymes.
· air embolism
o Obstruction of a vessel by air.
· alkalosis
o The blood is too alkaline, a pH of greater than 7.45.
· antidiuretic hormone (ADH)
o A hormone excreted by the hypothalamus in the brain that maintains blood pressure and fluid volume. Also known as vasopressin.
· antigens
o Substance that can trigger an immune response if foreign in the body.
· apoptosis
o Destruction of a cell.
· arrhythmias
o Abnormal heart rhythm.
· basic metabolic panel (BMP)
o A blood test that provides information regarding electrolyte and fluid balance and includes information regarding renal function and glucose levels.
· blood type
o A classification of the blood that includes 4 main groups: A, B, AB and O.
· bradycardia
o A heart rate that is less than the expected reference range.
· central venous access devices (CVADs)
o Device inserted in the body through a central vein such as the subclavian or jugular and allows administration of fluids, blood, medications, and other therapies.
· Chvostek sign
o Test which may indicate low calcium or magnesium levels. A positive result results in a twitching response of the side of the face when facial nerves are tapped.
· circulatory overload
o A complication of IV therapy in which too much fluid is administered too quickly.
· colloidal solutions
o Intravenous solutions that contain large molecules unable to pass through capillary membranes.
· complete metabolic panel (CMP)
o A blood test that provides information regarding electrolyte and fluid balance. In addition to those findings included in the BMP, the CMP also includes information regarding the body’s metabolism, including protein and liver function.
· creatinine (CR)
o Reflection of renal function; a byproduct of skeletal muscle contractions (creatine), which is then excreted through the urine.
· dehydration
o Excess water loss without a loss of sodium.
· diffusion
o Movement of solutes from an area of higher concentration to one of lower concentration.
· diuretics
o A category of medications that cause increased urination.
· edema
o Swelling due to excess fluid.
· electrocardiogram (ECG)
o A test to check heart activity including heart rate and rhythm.
· electrolytes
o Minerals in the body that conduct electricity.
· extracellular space
o The space outside the cell that includes the interstitial and intravascular areas.
· extravasation
o Inadvertent administration of a vesicant fluid into tissues surrounding an intravenous cannula.
· flow rate
o Rate at which fluids are being infused intravenously.
· fluid volume deficit
o A condition caused by the loss of water; also referred to as hypovolemia.
· fractionation
o Removing components of plasma for use.
· granulocytes
o A type of white blood cell responsible for immune responses during infections and allergic reactions that is comprised of neutrophils, eosinophils, and basophils.
· half-life
o The amount of time required for 50% of a drug to be excreted from the body.
· hematocrit
o A measure of RBCs in total blood volume.
· hemodialysis
o Process of filtering waste from the blood using a machine.
· hemoglobin
o A component of the red blood cell that carries oxygen and carbon dioxide to and from the cells.
· heparin
o Anticoagulant agent.
· homeostasis
o A state of equilibrium.
· Hypercalcemia
o Calcium level above expected reference range of 9 to 10.5 mg/dL (total calcium).
· hyperkalemia
o Potassium level above expected reference range of 3.5 to 5 mEq/L.
· hypermagnesemia
o Magnesium level above expected reference range of 1.3 to 2.1 mEq/L.
· hypernatremia
o Sodium level above expected reference range of 136 to 145 mEq/L.
· hyperparathyroidism
o Overactive parathyroid gland.
· hypertonic
o A solution that has more solutes than are present within the cell and results in fluid movement out of the cell.
· hyperventilation
o An increase in the rate and depth of breathign that leads to excessive loss of carbon dioxide from the blood.
· hypervolemia
o Fluid overload, the body has too much water.
· hypocalcemia
o Calcium level below expected reference range of 9 to 10.5 mg/dL (total calcium).
· hypoglycemia
o A blood glucose level below the expected reference range.
· hypokalemia
o Potassium level below expected reference range of 3.5 to 5 mEq/L.
· hypomagnesemia
o Magnesium level below expected reference range of 1.3 to 2.1 mEq/L.
· hyponatremia
o Sodium level below expected reference range of 136 to 145 mEq/L.
· hypoparathyroidism
o Body produces low levels of parathyroid hormone (PTH).
· hypotension
o A blood pressure that is below the expected reference range.
· hypotonic
o A solution that has fewer solutes than cell components and results in fluid moving into the cell.
· hypovolemia
o Decrease in blood volume due to body fluid or blood loss.
· hypovolemic shock
o When the body loses 20 percent or one-fifth of its blood or fluid supply.
· infiltration
o The inadvertent administration of fluid into the tissue surrounding an IV site due to displacement of the intravenous catheter tip.
· infusate
o The solution being infused through an intravenous access device.
· intake
o Amount taken in by the client, including oral, intravenous, and enteral routes, in addition to irrigation.
· interstitial space
o The space outside the cells; a component of the extracellular space.
· intracellular space
o The space within a cell.
· intravascular
o The space within the vascular system including within the chambers of the heart, the arteries, and veins.
· intravenous (IV)
o Within the vein.
· ionized calcium level
o Circulating calcium within the blood that is not attached to proteins.
· isotonic
o A solution that has the same number of solutes than cell components and results in no fluid movement into or our of the cell.
· kidney failure
o The inability of the kidneys to function properly and remove waste from the body.
· kidneys
o Organs that filter the blood and excrete waste as urine.
· leukocytes
o Also known as white blood cells; a component of the blood that make up the immune system.
· magnesium
o Electrolyte that helps with regulation of nerve and muscle function, blood pressure, and blood sugar levels, and making DNA, protein, and bone.
· metabolic acidosis
o When the blood in the body is too acidic, with an HCO3- less than 21 and a pH less than 7.35.
· metabolic alkalosis
o Blood in the body is too alkaline, with an HCO3- greater than 28 and a pH greater than 7.45.
· osmolality
o A measurement of the solutes within a solution.
· osmosis
o The movement of water across a semipermeable membrane from an area of higher concentration to one of lower concentration, such as fluid moving into or out of a cell, in an effort to maintain homeostasis.
· osteopenia
o Low bone mass.
· output
o The amount produced and eliminated by the client’s body, including urine, vomitus, drainage, and liquid stools.
· paralysis
o Loss of muscle function.
· paralytic ileus
o A cessation of intestinal motility.
· parathyroid hormone (PTH)
o Hormone secreted by the parathyroid gland that regulates serum calcium concentration.
· peripheral intravenous catheters
o Single-lumen plastic cannulas inserted into a peripheral vein, also known as peripheral venous access device or peripheral IV.
· peripherally inserted central catheters (PICCs)
o Device inserted peripherally through a vein in the arm with the tip centrally located to administer fluids, blood, medications, and other therapies.
· phlebitis
o Inflammation of the inner lining of the vein, the tunica intima, caused by mechanical, chemical, or bacterial factors.
· plasma
o Straw-colored liquid portion of blood containing water, proteins, salts, and antibodies.
· potassium
o Eectrolyte for nerve and muscle function, especially for the heart.
· potassium-sparing diuretic
o A medication that promotes the excretion of urine while retaining potassium.
· red blood cells (RBCs)
o Also known as erythrocyte; a component of the blood that contains hemoglobin that is responsible for oxygen and carbon dioxide transport throughout the body.
· rehydration
o Process of restoring lost water back into the body tissues and fluids either orally or through the administration of intravenous fluids.
· resin
o Medication taken to decrease potassium levels via bowel movements.
· respiratory acidosis
o 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.
· respiratory alkalosis
o Low carbon dioxide levels in the body, with a PaCO2 less than 35 and a pH greater than 7.45.
· Rh factor
o Protein of the blood type represented as (+) if present and (-) if absent.
· rhabdomyolysis
o Muscle breakdown resulting in the release of the protein myoglobin into the bloodstream, which can cause damage to the kidneys. Characterized by red-colored urine, low urine output, weakness, and muscle pain.
· scope of practice
o Sets forth the services or activities that licensed professionals are deemed competent and permitted to perform.
· sodium
o Electrolyte that supports the function of nerves and muscles, maintains normal blood pressure, and regulates fluid balance in the body.
· tachycardia
o Heart rate above the expected reference range.
· tachypnea
o Respiratory rate greater than expected range.
· third spacing
o Movement of fluid from the intravascular space (within the veins) to the interstitial space.
· thirst response
o Mechanism used to promote water consumption.
· thrombocytes
o Also known as platelets; responsible for blood clotting.
· tonicity
o A solution’s ability to make water move in our out of cells; includes isotonic, hypotonic, and hypertonic solutions.
· Trousseau sign
o Test that can indicate low calcium or magnesium levels and spasms in the wrist and hand (carpopedal spasms) when a blood pressure cuff is inflated above the systolic blood pressure.
· urine specific gravity
o A test that measures the solutes in a sample of urine and provides information regarding the body’s fluid balance. The expected reference range of urine specific gravity is 1.005 to 1.030.
· vasopressin
o A hormone excreted by the hypothalamus in the brain that maintains blood pressure and fluid volume. Also knows as antidiuretic hormone (ADH).
· vesicants
o An intravenous fluid that is damaging to the surrounding tissue outside the vein.
· white blood cells (WBCs)
o Also known as leukocytes; a component of the blood that makes up the immune system.
· whole blood
o Combination of red cells, white cells, and platelets in blood plasma
This solution is not the best option for a client experiencing
vomiting and diarrhea.
A 0.45% sodium chloride solution is
hypotonic and is used to treat hypernatremia and diabetic ketoacidosis.
This solution is not the best option for a client experiencing
vomiting and diarrhea.
A 0.9% sodium chloride solution is
isotonic and is used for hydration needs such as from vomiting, diarrhea, hemorrhage, and shock. This is the most appropriate solution for the provider to prescribe for this client.
A 3% sodium chloride solution is
hypertonic and is used for emergent replacement of solutes, such as in clients experiencing manifestations of hyponatremia. This solution can cause fluid shifts and is not the best option for a client experiencing vomiting and diarrhea.
A calcium level of 10 mg/dL is
within the expected reference range of 9 to 10.5 mg/dL.
A client who has hypomagnesemia might experience
weakness, which could make it difficult to ambulate. Therefore, the nurse should identify that difficulty ambulating, rather than the ability to ambulate without assistance, could be an indication of hypomagnesemia.
A client who is receiving blood or blood products should always have
two nurses check the blood unit label and client identification for comparison. The newly licensed nurse should take this action because it decreases the chance of error.
A client with AB+ blood type can receive
A- blood as the blood types are compatible. Clients who have type AB+ are universal receivers, which means they can receive blood from any donor blood of any blood type.
Clients who have A- blood type can receive blood from donors who have
A- blood type.
A magnesium level of 3 mEq/L is
above the expected reference range of 1.3 to 2.1 mEq/L. report this finding to the provider.
A potassium level of 4.5 mEq/L is
within the expected reference range of 3.5 to 5 mEq/L.
A sodium level of 138 mEq/L is
within the expected reference range of 135 to 145 mEq/L.
A state of respiratory alkalosis indicates that the client’s bicarbonate level is
currently above the expected reference range. The goal of treatment should be to lower the level of bicarbonate back to within the expected reference range for HCO3- of 21 to 28 mEq/L.
A state of respiratory alkalosis indicates that the client’s carbon dioxide level is currently
below the expected reference range. The goal of treatment should be to raise the level of carbon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm Hg.
A state of respiratory alkalosis indicates that the client’s pH level is currently
above the expected reference range. The goal of treatment should be to lower the pH level to within the expected reference range of 7.35 to 7.45.
A state of respiratory alkalosis indicates the client is likely experiencing an
elevated respiratory rate. Hyperventilation can cause respiratory alkalosis because carbon dioxide is eliminated as expirations increase. The goal of treatment should be to lower the client’s respiratory rate.
Clients who have A+ blood type can receive blood from donors who have
A- blood type.
Clients who have AB- blood type can receive blood from donors who have
A- blood type.
Clients who have AB+ blood type can receive blood from donors who have
A- blood type.
Although an intestinal virus increases the client’s risk for a f
luid and electrolyte imbalance during infection, this would not cause a fluid and electrolyte balance after 2 weeks.
An air embolism is a medical emergency that occurs when a
vessel such as the lung is obstructed by air. Indications of an air embolism include sudden difficulty in breathing, coughing, wheezing, hypotension, tachycardia, and chest or shoulder pain, but not weight gain.
Clients who have B+ blood type cannot receive blood from donors who have
A- blood type.
Blood can be administered over a period of
1 to 4 hr. For a client who is at risk for circulatory overload, such as a client who has heart failure, a disorder in which compromised cardiac output results in poor tissue perfusion and fluid overload, the transfusion should be administered slowly (maximum time of 4 hr) to avoid increasing the workload of the heart.
Blood can be administered over a period of 1 to 4 hr. For a client who is at risk for circulatory overload, such as a client who has heart failure, a disorder in which
compromised cardiac output results in poor tissue perfusion and fluid overload, the transfusion should be administered slowly (maximum time of 4 hr) to avoid increasing the workload of the heart.
Clients who have O+ blood cannot receive blood from donors with type
AB- or type A- blood.
Clients who have type O+ blood can only receive blood from donors who have type
O- or type O+ blood. Clients who have type O- blood are universal donors, meaning that anyone can receive their blood, regardless of blood type.
Clients who have type O+ blood cannot receive blood from donors with type
B- or type A+ blood.
The nurse should identify that an older adult client who has decreased kidney function is at an increased risk for
dehydration.
Decreased thirst response is correct. The nurse should expect that an older adult client who has a decreased thirst response might not drink enough fluids daily, which puts them at increased risk for
dehydration.
Decreased total body fluid is correct. The nurse should expect that an older adult client who has decreased total body fluid to be at increased risk for
dehydration.
Decreased urine output is non-urgent because
it is an early and expected finding of hypovolemia.
Dextrose 10% in water is
hypertonic and is used to treat hypoglycemia. This solution is not the best option for a client experiencing vomiting and diarrhea.
Dry mucous membranes are non-urgent because
it is an early and expected finding of hypovolemia.
Foods with high water content such as cucumbers help rehydrate the client and
decrease the risk for dehydration.
Eating watermelon daily is incorrect. Foods with high water content such as watermelon help rehydrate the client and
decrease the risk for dehydration.
Extravasation
is a localized complication of IV therapy that occurs when a vesicant medication or fluid moves from the vein into the surrounding tissue.
Indications of extravasation include
cool skin surrounding the IV site, localized edema, and report of pain from the client, but not weight gain.
Extreme thirst is not a manifestation of
hypomagnesemia.
A client who is experiencing extreme thirst might be experiencing
hypernatremia.
HCO3- 19 mEq/L is correct. The nurse should expect a client who is experiencing metabolic acidosis to have an HCO3- level
below the expected reference range of 21 to 28 mEq/L, such as an HCO3- level of 19 mEq/L.
Instead of using a tourniquet, the nurse should apply a
blood pressure cuff set to 30 mm Hg prior to starting an IV for this client. This will help protect the client’s extremity from bruising and bleeding.
Metabolic acidosis is indicated by a pH value
below the expected reference range and an HCO3- value below the expected reference range.
Metabolic acidosis is indicated by a pH value less than 7.35 and an HCO3- value
less than 21 mEq/L.
Metabolic alkalosis is indicated by a pH value above the expected reference range and an HCO3- value
above the expected reference range.
Nausea and vomiting are early manifestations of
hypomagnesemia.
O+ is incorrect. Clients who have O+ blood type cannot receive blood from donors who have
A- blood type.
PaCO2 35 mm Hg is correct. The nurse should expect a client who is experiencing metabolic acidosis to have a PaCO2 level
within the expected reference range of 35 to 45 mm Hg, such as a PaCO2 level of 35 mm Hg.
PaCO2 49 mm Hg is incorrect. The nurse should expect a client who is experiencing metabolic acidosis to have a PaCO2 level
within the expected reference range of 35 to 45 mm Hg.
An elevated PaCO2 level of 49 mm Hg indicates
respiratory acidosis.
pH 7.29 is correct. The nurse should expect a client who is experiencing metabolic acidosis to have pH level
below the expected reference range of 7.35 to 7.45, such as a pH level of 7.29.
pH 7.49 is incorrect. Although pH 7.49 is above the expected reference range of 7.35 to 7.45, this is not an indication of
metabolic acidosis.
A pH value above the expected reference range indicates a state of
alkalosis.
Phlebitis is a
localized complication of IV therapy that occurs with inflammation of the inner lining of the vein
. Indications of phlebitis include
pain at the IV insertion site and surrounding area, swelling, erythema, and the presence of a palpable cord along the vein, but not weight gain.
PICC lines can be used to provide
fluids for clients with dehydration when peripheral access is unattainable.
PICC lines have less incidence of
infiltration due to the location of their insertion site.
PICC lines are placed in
large veins, such as the basilic or cephalic vein in the forearm or the antecubital fossa.
Reassessment should occur if there is a change in the client’s condition. If no change is evident, the nurse should continue to
move into the next stage of the nursing process.
Report of thirst is non-urgent because i
t is an early and expected finding of hypovolemia.
Requesting an extra tray to eat can indicate an increased
appetite. The nurse should identify that a decreased appetite, rather than an increased appetite, is a manifestation of hypomagnesemia.
Respiratory acidosis is indicated by a pH value
less than 7.35 and a PaCO2 value greater than 45 mm Hg.
Respiratory acidosis is indicated by a pH value
less than 7.35 and a PaCO2 value greater than 45 mm Hg.
Respiratory alkalosis is indicated by a pH value
above the expected reference range and a PaCO2 value below the expected reference range.
Respiratory alkalosis is indicated by a pH value
greater than 7.45 and a PaCO2 level less than 35 mm Hg.
Respiratory alkalosis is indicated by a pH value
greater than 7.45 and a PaCO2 value less than 35 mm Hg.
Reviewing the client’s ABG values is part of the
evaluation stage of the nursing process.
During the evaluation stage, the nurse should determine
if the actions taken in the implementation stage were successful in meeting the goals in the client’s plan of care.
The assessment stage of the nursing process includes
collecting subjective and objective data from the client to include when developing a plan of care. Reviewing the client’s latest ABG values is not part of the assessment stage.
The charge nurse should intervene if the newly licensed nurse selects
0.45% sodium chloride to prime the tubing.
The nurse should identify that 0.9% sodium chloride is the only IV solution that should be used to
prime the tubing for blood administration.
The client denies being confused is correct. The client reporting that they are not confused is an indication of
adequate sodium levels. Therefore, this is an indication that the treatment for hyponatremia has been effective.
The client is not at risk for excessive sweating that could lead to a fluid and electrolyte imbalance while working in a
controlled temperature of 21.1° C (70° F).
The client reports a headache is incorrect. Headache is a manifestation of
hyponatremia, rather than an indication that the treatment for hyponatremia has been effective.
The client reports being nauseated is incorrect. Nausea is a manifestation of
hyponatremia, rather than an indication that the treatment for hyponatremia has been effective.
The client reports feeling tired is incorrect. Fatigue is a manifestation of
hyponatremia, rather than an indication that the treatment for hyponatremia has been effective.
The client states their muscle spasms are absent is correct. The absence of muscle spasms indicates that the treatment for hyponatremia has been
effective.
The evaluation stage is the
final stage of the nursing process. It takes place following the implementation of the plan of care.
The first action the nurse should take when using the airway, breathing, circulation approach to client care is to
elevate the head of the client’s bed
. Placing the client in the Fowler’s or semi-Fowler’s position will
promote effective breathing and chest expansion.
The implementation stage of the nursing process includes providing
nursing interventions that put the goals of the planning stage into action. Reviewing the client’s latest ABG values is not part of the implementation stage.
The newly licensed nurse should discard the tubing after
each unit of blood is administered, or every 4 hr, whichever comes first.
The newly licensed nurse should use tubing with a
filter during blood administration to remove any clots and platelet clumps that might be present in the unit of blood.
The nurse should apply a warm compress to the selected IV site. Applying a cold compress to the site could compromise the
client’s circulation.
The nurse should ask the client to hold the extremity in a dependent position to
enhance blood flow to the site.
The nurse should ask the client to make a fist with the fingers of the selected extremity. The client should then open and close their fist several times to
enhance blood flow to the area.
The nurse should identify that 0.9% sodium chloride is the only IV solution that should be used to
prime the blood tubing.
The nurse should identify that a client who has been receiving IV therapy and whose daily weight has increased is at risk for
circulatory overload.
The nurse should assess the client for other indications of circulatory overload, including
tachycardia, increased blood pressure, edema, cough, and tachypnea. The nurse should also inform the provider of the client’s increased weight.
The nurse should identify that working outside in high temperatures for an extended period can cause profuse sweating and lead to a
fluid and electrolyte imbalance.
The nurse should initiate continuous cardiac monitoring for a client who is experiencing
hypoxia to ensure the client does not develop dysrhythmias. However, there is another action the nurse should take first.
The nurse should initiate continuous SpO2 monitoring for a client who is experiencing
hypoxia to ensure the client does not decompensate. However, there is another action the nurse should take first.
The nurse should instruct the client to d
eep breathe and cough to clear their airway. However, there is another action the nurse should take first.
The nurse should instruct the newly licensed nurse to perform range of motion exercises on the client’s extremity that
contains the IV site.
The nurse should not plan to infuse blood over 6 hr because
after 4 hr the blood can become unsafe due to bacterial invasion.
The nurse should remain with the client for the first 15 min after the transfusion has started to
make sure the client does not experience a transfusion reaction.
The planning stage of the nursing process includes
developing goals and actions to provide care for a client. Reviewing the client’s latest ABG values is not part of the planning stage.
The purpose of the PICC line is to
help prevent the need for multiple peripheral IV sticks as it provides more reliable access that can be used long term.
The unit of blood is compatible with the client’s blood type. However, the nurse should ensure that the blood unit had been verified by
two nurses before initiating the transfusion.
Metabolic alkalosis is indicated by a pH value
above the expected reference range of 7.35 to 7.45, an HCO3- value above the expected reference range of 21 to 28 mEq/L, and a PaCO2 level within the expected reference range of 35 to 45 mm Hg.
Respiratory acidosis is indicated by a pH value
below the expected reference range of 7.35 to 7.45 and a PaCO2 value above the expected reference range of 35 to 45 mm Hg.
This nurse should monitor the client who has a PICC for complications, such as
infection at the access site and blood clots. It is important for the nurse to use aseptic technique when accessing and flushing the PICC line and during dressing changes.
When a diuretic dose is decreased, the client will experience a
decrease in urination. This should not cause a fluid and electrolyte imbalance.
When using the urgent vs non-urgent priority framework, the nurse determines that the priority finding is a
decrease in the client’s level of consciousness.
Decreased level of consciousness is an indication that
hypovolemia has progressed to a critical level and requires immediate intervention.
PaO2 76 mm Hg. This value is below the expected reference range of 80 to 100 mm Hg and could be an indication the client is
decompensating.
HYPERNATREMIA (BIG AND BLOATED) - FRIED SALT
FLUSHED SKIN
RESTLESS / ANXIOUS
INCREASE BP
EDEMA (PITTING)
DECREADES URINE OUTPUT
THIRST (DRY MUCOUS MEMBRANES)
LOW GRADE FEVER
HYPONATREMIA
STUPOR / COMA
ANOREXIA
LETHARGY
TACHYCARDIA
LIMP MUSCLES (MUSCLE WEAKNESS)
ORTHOSTATIC HYPOTENSION
SEIZURES / HEADACHES
STOMACH CRAMPING (HYPERACTIVE BOWELS)
