Exam 2 (Ch. 17) PPT

Question 1

Fluid Volume Imbalances

What is a homeostasis disruption?

Answer 1

Fluid and electrolyte imbalances arise when a significant illness or injury interferes with the body’s ability to maintain a stable internal environment (homeostasis).

Question 2

Fluid Volume Imbalances

What type of clients do you think could have a fluid
volume imbalance?

Answer 2

Vulnerability: Patients experiencing major physiological stress are at risk. This includes those with:
Acute illnesses: Infections, fevers, gastrointestinal issues (vomiting, diarrhea)
Chronic diseases: Heart failure, kidney disease, diabetes
Trauma: Burns, fractures, head injuries
Surgical procedures: Especially those involving significant blood loss or NPO status
Extremes of age: Infants and elderly individuals are more susceptible due to immature or declining organ function.

Question 3

A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first for potential fluid volume imbalance?

Clients:

1. A 78-year-old client with a history of heart failure admitted for exacerbation of shortness of breath.
2. A 35-year-old client with a fractured tibia scheduled for open reduction internal fixation (ORIF) in the morning.
3. A 50-year-old client with well-controlled type 2 diabetes admitted for routine blood glucose monitoring.
4. A 20-year-old client with gastroenteritis experiencing nausea, vomiting, and diarrhea for the past 24 hours.

Answer 3

4 A 20-year-old client with gastroenteritis experiencing nausea, vomiting, and diarrhea for the past 24 hours.

Rationale: The client with gastroenteritis is at the highest risk for rapid fluid volume deficit due to the ongoing losses from vomiting and diarrhea. This poses an immediate threat to their physiological stability. While the other clients have potential or chronic risks, the gastroenteritis patient’s acute fluid loss takes priority.

Question 4

Scenario: A client is admitted with a diagnosis of heart failure exacerbation. The nurse monitors the client’s daily weights and observes the following trend:

Day 1: 70 kg
Day 2: 71.5 kg
Day 3: 72.8 kg
Question: What is the most likely explanation for the client’s weight gain?

A. Fluid volume deficit
B. Fluid volume overload
C. Improved nutritional intake
D. Increased muscle mass

Answer 4

B. Fluid volume overload

Rationale: In heart failure exacerbation, the heart’s pumping ability is compromised, leading to fluid retention. The progressive weight gain over the three days strongly suggests fluid accumulation rather than fluid loss, improved nutrition, or muscle gain.

Question 5

Which of the following clients are at increased risk for developing a fluid volume deficit? (Select all that apply.)

A. A client with uncontrolled diabetes mellitus
B. A client with syndrome of inappropriate antidiuretic hormone (SIADH)
C. A client with profuse sweating due to heat exposure
D. A client experiencing continuous vomiting and diarrhea
E. A client with chronic kidney disease
F. A client with a head injury resulting in increased intracranial pressure

Answer 5

A, C, D, and E

Rationale:
A. Uncontrolled Diabetes: High glucose levels lead to osmotic diuresis, resulting in excessive fluid loss.
C. Profuse Sweating: Sweating is a physiological response to heat, but excessive sweating without adequate fluid replacement can lead to dehydration.
D. Vomiting and Diarrhea: These directly result in the loss of fluids and electrolytes.
E. Chronic Kidney Disease: Damaged kidneys may have difficulty regulating fluid balance, potentially leading to both deficits and excesses, but in this case, we are focusing on potential deficits.

Question 6

Fluid Volume Deficit (Hypovolemia)

What is hypovolemia, what are some causes?

Answer 6

Hypovolemia refers to a decrease in the volume of circulating blood in the body. It’s often used interchangeably with dehydration, but technically, dehydration refers to a loss of water specifically, while hypovolemia can include loss of other fluids and electrolytes.
Causes:
▪ Abnormal loss of bodily fluids
▪ Diarrhea
▪ Vomiting
▪ Hemorrhage
▪ Polyuria
▪ Inadequate fluid intake
▪ Overuse of diuretics
▪ NG Suction
▪ High fever
▪ Heatstroke

Question 7

A nurse is caring for a client with severe vomiting and diarrhea. Which of the following findings would indicate fluid volume deficit? (Select all that apply.)

A. Bounding pulse
B. Decreased skin turgor
C. Hypertension
D. Increased urine specific gravity
E. Flat neck veins
F. Moist mucous membranes

Answer 7

B, D, E

Rationale:

Decreased skin turgor: A classic sign of dehydration.
Increased urine specific gravity: Indicates concentrated urine, as the kidneys try to conserve water.
Flat neck veins: Suggests decreased venous return due to reduced blood volume.

Question 8

Hypovolemia - Manifestations

What are some S/S of hypovolemia?

Answer 8

Neurological: Restlessness, drowsiness, lethargy, confusion, seizures, coma (in severe cases). These reflect the impact of dehydration on brain function.
Sensory/Hydration: Thirst, dry mucous membranes.
Integumentary: Cold, clammy skin, decreased skin turgor, decreased capillary refill.
Cardiovascular: Decreased blood pressure, decreased heart rate, increased respiratory rate.
Renal: Decreased urine output.
General: Weakness, dizziness, weight loss.

Question 9

A nurse is assessing a client with suspected hypovolemia. Which of the following findings are consistent with fluid volume deficit? (Select all that apply.)

A. Increased skin turgor
B. Moist mucous membranes
C. Restlessness and confusion
D. Decreased capillary refill
E. Bounding pulse
F. Decreased urine output

Answer 9

C, D, F

Rationale: Restlessness/confusion (neurological changes), decreased capillary refill (integumentary), and decreased urine output (renal) are all consistent with hypovolemia.

Question 10

A client with severe diarrhea is exhibiting manifestations of fluid volume deficit. The nurse notes a decreased heart rate. What is the nurse’s most appropriate action?

A. Administer intravenous fluids as prescribed.
B. Document the finding and continue to monitor the client.
C. Assess the client for other signs and symptoms of hypovolemia and notify the healthcare provider.
D. Check the client’s medication administration record for medications that may lower the heart rate.

Answer 10

C

Rationale: The decreased heart rate is an atypical finding in hypovolemia and warrants further investigation. The nurse should assess for other signs and symptoms, review the client’s history and medications, and promptly notify the provider about this concerning finding.

Question 11

A nurse is caring for a client with persistent vomiting and diarrhea. Which of the following assessments is the highest priority?

A. Assessing the client’s skin turgor.
B. Monitoring the client’s urine output.
C. Auscultating the client’s lung sounds.
D. Checking the client’s neurological status.

Answer 11

D

Rationale: While all assessments are important, neurological changes (such as confusion, lethargy, or decreased level of consciousness) can indicate worsening hypovolemia and require immediate intervention to prevent potential complications like seizures or coma. Therefore, neurological status is the highest priority.

Question 12

Fluid Volume Excess (Hypervolemia)

What is hypervolemia? What causes it?

Answer 12

Hypervolemia, also known as fluid overload, is a condition characterized by an abnormal increase in the volume of circulating blood in the body. It involves an excess of both water and sodium.
Abnormal retention of fluids
Causes:
Heart Failure: The heart’s inability to effectively pump blood can lead to fluid buildup.
Renal Failure: Impaired kidney function reduces the body’s ability to eliminate excess fluids.
Long-term Corticosteroid Use: These medications can cause sodium and water retention.
Excessive Isotonic or Hypotonic IV Fluids: Overadministration of these fluids can lead to fluid overload.

Question 13

Hypervolemia - Manifestations

What are some S/S of Hypervolemia?

Answer 13

▪ Headache, confusion, lethargy
▪ Peripheral Edema
▪ Jugular vein distention
▪ Bounding pulse, increased blood
pressure
▪ Polyuria with normal renal function
▪ Dyspnea, crackles, pulmonary
edema
▪ Muscle spasms
▪ Weight Gain
▪ Seizures, coma

Question 14

A patient with heart failure is admitted with fluid volume excess. Which of the following assessment findings is the highest priority for the nurse to address?

A. Edema in the feet and ankles.
B. Crackles in the lungs.
C. Weight gain of 2 pounds.
D. Jugular venous distention (JVD).

Answer 14

B

Rationale: Crackles in the lungs indicate fluid in the lungs (pulmonary edema), which can impair oxygenation and lead to respiratory distress. This is the highest priority as it poses an immediate threat to the patient’s well-being.

Question 15

A patient with chronic renal failure is admitted with hypervolemia. Which of the following interventions would the nurse anticipate to be prescribed by the healthcare provider?

A. Increased oral fluid intake.
B. Administration of hypotonic intravenous fluids.
C. Restriction of dietary sodium.
D. Encouraging consumption of foods high in potassium.

Answer 15

C

Rationale: Sodium restriction is a key component of managing hypervolemia as sodium causes the body to retain water. The other options would worsen fluid overload in this patient.

Question 16

A patient is receiving intravenous fluids at a high rate. The nurse observes the following signs and symptoms: crackles in the lungs, increased blood pressure, and bounding pulse. What is the nurse’s most appropriate action?

A. Slow down the IV infusion rate and notify the healthcare provider.
B. Administer oxygen and diuretics as prescribed.
C. Document the findings and continue to monitor the patient.
D. Check the patient’s electrolyte levels.

Answer 16

A

Rationale: These are classic signs of fluid overload due to the rapid IV infusion. The most appropriate action is to slow the infusion rate to prevent further fluid accumulation and notify the provider about the patient’s status. The other actions may be necessary but are secondary to stopping the immediate cause of the problem.

Question 17

Nursing Management- Fluid Imbalance

What are some key nursing managements for fluid imbalances?`

Answer 17

▪ Assess patient for manifestations of fluid imbalances.
▪ Give IV fluids and medications as ordered.
▪ Give O2 therapy as ordered.
▪ Implement fall precautions.
▪ Monitor patient for effectiveness of therapy.
▪ Obtain daily weights and vital signs.
▪ Accurate intake and output.
▪ Elevate edematous extremities.

Question 18

A patient with fluid volume excess develops shortness of breath and crackles in the lungs. What is the nurse’s most appropriate initial action?

A. Administer oxygen therapy as ordered.
B. Notify the healthcare provider.
C. Elevate the head of the bed.
D. Administer diuretics as prescribed.

Answer 18

A

Rationale: While all options are important, the most immediate action is to administer oxygen to address the patient’s respiratory distress.

Question 19

What is paracentesis? Why is it performed?

Answer 19

Definition: A procedure in which a needle is inserted into the abdomen to remove excess fluid (ascites) from the peritoneal cavity.
Reasons for procedure: Ascites (fluid buildup in the abdomen) can be caused by liver disease, heart failure, kidney disease, or cancer. Paracentesis is done to relieve abdominal pressure, improve breathing, and obtain fluid for diagnostic testing.

Question 20

What are some nursing considerations for paracentesis?

Answer 20

Nursing considerations:
Explain the procedure to the patient.
Obtain informed consent.
Assist the patient to void before the procedure to reduce the risk of bladder puncture.
Position the patient in a semi-Fowler’s or sitting position.
Monitor vital signs throughout the procedure.
Measure abdominal girth before and after the procedure.
Observe for signs of complications (e.g., bleeding, infection, peritonitis).

Question 21

What is thoracentesis? Why is it performed?

Answer 21

Definition: A procedure in which a needle is inserted into the chest cavity (pleural space) to remove excess fluid or air.
Reasons for procedure: Pleural effusion (fluid buildup around the lungs) can be caused by heart failure, pneumonia, cancer, or pulmonary embolism. Thoracentesis is done to relieve respiratory distress, obtain fluid for diagnostic testing, or instill medication into the pleural space.

Question 22

What are some nursing considerations for thoracentesis?

Answer 22

Nursing considerations:
Explain the procedure to the patient.
Obtain informed consent.
Position the patient upright with arms resting on an overbed table.
Monitor vital signs throughout the procedure.
Observe for signs of complications (e.g., pneumothorax, bleeding, infection).
Encourage deep breathing and coughing after the procedure.
Obtain a post-procedure chest x-ray as ordered.

Question 23

What are the 3 Common Crystalloid Solutions?

Answer 23

1. Hypotonic
2. Hypertonic
3. Isotonic

Question 24

IV Fluid and Electrolyte Replacement

What are the 2 purposes of IV fluid therapy?

Answer 24

Maintenance: To provide ongoing daily needs for fluids and electrolytes when oral intake is insufficient or not possible. This could be due to various reasons like surgery, illness, or inability to swallow.
Replacement: To correct existing fluid or electrolyte deficits that have occurred due to losses (e.g., vomiting, diarrhea, hemorrhage) or ongoing conditions.

Question 25

# IV Fluid and Electrolyte Replacement How are IV fluids categorized?

Answer 25

By tonicity - This refers to the concentration of solutes in the fluid compared to the concentration of solutes in the blood (plasma).

Question 26

A patient is admitted with dehydration due to severe vomiting and diarrhea. Which of the following is the MOST important initial step in managing this patient's fluid needs? A. Administering antiemetics to stop the vomiting. B. Inserting an IV catheter and initiating fluid replacement. C. Obtaining a detailed medical history and performing a physical exam. D. Ordering laboratory tests to assess electrolyte levels.

Answer 26

C Rationale: While all steps are important, obtaining a medical history and performing a physical exam are crucial first to assess the severity of dehydration and determine the appropriate course of treatment.

Question 27

A patient is receiving a hypertonic IV solution. Which of the following assessments should the nurse prioritize during the infusion? A. Monitoring urine output. B. Assessing for signs of fluid overload. C. Checking the IV site for infiltration. D. Monitoring blood glucose levels.

Answer 27

B Rationale: Hypertonic solutions can cause fluid to shift from the cells into the vascular space, potentially leading to fluid overload. Monitoring for signs of fluid overload is the priority.

Question 28

# Hypotonic IV Fluids What are hypotonic IV fluids? What are their effect on fluid distribution?

Answer 28

Hypotonic IV fluids have a lower osmolality (concentration of solutes) than plasma (blood). Effect on Fluid Distribution: Because of the lower osmolality, hypotonic fluids dilute the extracellular fluid (ECF). This causes water to move from the ECF into the intracellular fluid (ICF) via osmosis, leading to cell swelling. ## Footnote Key Monitoring Point: It is crucial to monitor for changes in mentation (mental status) as rapid shifts in fluid balance can lead to cerebral edema (swelling of the brain).

Question 29

# Hypotonic IV Fluids What are some uses for hypotonic IV fluids?

Answer 29

Maintenance Fluids: Hypotonic solutions can be used for routine maintenance of fluids, especially when patients are NPO (nothing by mouth) and need fluids to replace insensible losses (e.g., sweating, breathing). Hypernatremia Treatment: They are also used to treat hypernatremia (high sodium levels) by diluting the excess sodium in the ECF.

Question 30

Which of the following statements are correct regarding hypotonic IV fluids? (Select all that apply.) A. They have a higher osmolality than plasma. B. They cause water to move from the ECF to the ICF. C. They can be used to treat hypernatremia. D. They are appropriate for patients with increased ICP. E. They can lead to cell swelling.

Answer 30

B, C, E Rationale: Hypotonic solutions have a lower osmolality than plasma and are contraindicated in patients with increased ICP as they can worsen cerebral edema.

Question 31

A patient is ordered to receive a hypotonic IV solution. Which of the following assessments should the nurse prioritize before initiating the infusion? A. Checking the patient's blood glucose level. B. Assessing the patient's neurological status. C. Monitoring the patient's urine output. D. Assessing the patient's skin turgor.

Answer 31

B Rationale: Changes in mentation can be an early sign of cerebral edema, a potential complication of hypotonic fluid administration. Therefore, assessing neurological status is the priority.

Question 32

A patient receiving a hypotonic IV solution develops a sudden change in mentation (confusion). Which of the following actions should the nurse take FIRST? A. Slow down the IV infusion rate. B. Notify the healthcare provider. C. Assess the patient's vital signs. D. Stop the infusion and administer a hypertonic solution.

Answer 32

A Rationale: The change in mentation could indicate cerebral edema. The FIRST action is to slow the infusion rate to minimize further fluid shift into the cells. The healthcare provider should be notified, and vital signs should be assessed, but slowing the infusion is the priority.

Question 33

# D5W (5% Dextrose in Water) What type of crystalloid solutions is D5W?

Answer 33

D5W is technically considered isotonic because its initial osmolality is similar to that of plasma. However, the dextrose (sugar) is rapidly metabolized by the body, leaving behind free water and becoming hypotonic.

Question 34

# D5W (5% Dextrose in Water) What are the metabolic effect and net results of D5W?

Answer 34

Metabolic Effect: The dextrose is quickly metabolized into carbon dioxide and water, providing a small amount of calories (170 cal/L) and essentially becoming free water. Net Result: The net result of D5W infusion is the provision of free water, which dilutes the body fluids.

Question 35

# D5W (5% Dextrose in Water) What are the uses of D5W?

Answer 35

Replacing Water Losses: D5W is used to replace water losses, such as those due to dehydration or excessive sweating. Preventing Ketosis: The small amount of dextrose can help prevent ketosis (a metabolic state caused by fat breakdown) in patients who are NPO (nothing by mouth). | Provides 170 cal/L ## Footnote Not a Replacement for Electrolytes

Question 36

# D5W (5% Dextrose in Water) What are some risk of D5W?

Answer 36

Hyperglycemia: In some patients, particularly those with diabetes, D5W can cause hyperglycemia (high blood sugar). Fluid Overload: Like any IV fluid, D5W can contribute to fluid overload if infused in large amounts or too rapidly. Dilution of Electrolytes: Because D5W dilutes body fluids, it can also dilute electrolyte concentrations, potentially leading to imbalances.

Question 37

Which of the following statements are correct regarding D5W? (Select all that apply.) A. It is technically considered isotonic. B. It provides electrolytes. C. It provides calories. D. It can be used to treat dehydration. E. It can cause hyperglycemia.

Answer 37

A, C, D, E

Question 38

A patient with dehydration is ordered to receive D5W. Which of the following assessments should the nurse prioritize before initiating the infusion? A. Checking the patient's blood glucose level. B. Assessing the patient's neurological status. C. Monitoring the patient's urine output. D. Assessing the patient's skin turgor.

Answer 38

A Rationale: Because D5W can cause hyperglycemia, checking the patient's baseline blood glucose level is the priority, especially for diabetic patients.

Question 39

A patient is receiving D5W for maintenance fluids. Which of the following findings would indicate that the patient is developing fluid overload? A. Decreased blood pressure. B. Crackles in the lungs. C. Poor skin turgor. D. Increased urine output.

Answer 39

B Rationale: Crackles in the lungs are a sign of pulmonary edema (fluid in the lungs), which indicates fluid overload.

Question 40

A patient with a history of diabetes is ordered to receive D5W. Which of the following actions should the nurse take to minimize the risk of hyperglycemia? A. Infuse the D5W at a rapid rate. B. Monitor the patient's blood glucose level regularly. C. Administer insulin before the D5W infusion. D. Use a hypotonic solution instead of D5W.

Answer 40

B Rationale: Regular blood glucose monitoring is essential to detect and manage hyperglycemia. Slowing the infusion rate might help, but monitoring is the priority. Insulin administration would depend on the glucose level and physician orders. A hypotonic solution might not be appropriate for the patient's specific fluid and electrolyte needs.

Question 41

# Isotonic IV Fluids What are the osmolality and fluid distribution for isotonic IV fluids?

Answer 41

Osmolality: Isotonic solutions have a similar osmolality (concentration of dissolved particles) to that of the body's extracellular fluid (ECF), particularly the plasma. Fluid Distribution: When infused, isotonic solutions primarily remain within the extracellular space (both the intravascular and interstitial compartments). There is minimal to no net movement of fluid across cell membranes into the intracellular space (ICF).

Question 42

# Isotonic IV Fluids What are the effect on cells and primary uses of isotonic IV fluids?

Answer 42

Effect on Cells: Because there's no significant fluid shift, isotonic solutions do not cause cells to shrink or swell. Primary Use: Isotonic fluids are ideal for replacing fluid volume deficits that occur in conditions like: * Hemorrhage (blood loss) * Dehydration (loss of fluids) * Vomiting and Diarrhea * Surgery

Question 43

# Isotonic IV Fluids What are somethings to monitor for with isotonic IV fluids?

Answer 43

Fluid Overload: Signs include edema (swelling), crackles in the lungs, jugular venous distention (JVD), and rapid weight gain. Electrolyte Imbalances: Although isotonic fluids are generally balanced, rapid or excessive infusion can still lead to electrolyte disturbances.

Question 44

A patient who experienced significant blood loss during surgery requires intravenous fluid replacement. Which type of IV fluid would be MOST appropriate to administer initially? A. 0.45% Normal Saline (1/2 NS) B. D5W (5% Dextrose in Water) C. 0.9% Normal Saline (NS) D. 3% Hypertonic Saline

Answer 44

C Rationale: 0.9% Normal Saline is an isotonic solution that is commonly used for initial fluid resuscitation in cases of blood loss or dehydration.

Question 45

# Normal Saline What is normal saline's tonicity, compostions, & uses? | Other Names: NS, 0.9% saline, NSS (Normal Saline Solution)

Answer 45

Tonicity: Isotonic - meaning it has a similar concentration of dissolved particles as the body's extracellular fluid (ECF). Composition: Contains slightly more sodium chloride (NaCl) than the ECF. Use Cases: * Fluid and Sodium Loss: Used when both fluid and sodium are lost, such as in hemorrhage, vomiting, and diarrhea. * Blood Product Administration: The only solution that can be used with blood products. This is because other solutions can cause red blood cells to swell and rupture (hemolysis).

Question 46

# Normal Saline What are some important considerations for normal saline and what should you monitor?

Answer 46

Volume Expansion: Since it's isotonic, it expands the ECF volume without causing a significant shift of fluid into or out of the cells. Electrolyte Imbalances: It doesn't provide other electrolytes, so prolonged use can lead to imbalances. Acid-Base Balance: Can cause mild metabolic acidosis in large volumes due to the high chloride content. Monitoring * Fluid Overload: Signs include edema (swelling), crackles in the lungs, jugular venous distention (JVD), and rapid weight gain. * Electrolyte Imbalances: Especially potassium, as it can be diluted.

Question 47

Which of the following statements accurately describe normal saline (0.9% NaCl)? (Select all that apply.) A. It is a hypotonic solution. B. It is used to replace both fluid and sodium losses. C. It is the only solution compatible with blood products. D. It can cause cells to shrink. E. It can lead to electrolyte imbalances with prolonged use.

Answer 47

B, C, E

Question 48

A patient who experienced significant blood loss during surgery requires intravenous fluid replacement. Which type of IV fluid would be MOST appropriate to administer initially? A. 0.45% Normal Saline (1/2 NS) B. D5W (5% Dextrose in Water) C. 0.9% Normal Saline (NS) D. Lactated Ringer's (LR)

Answer 48

C Rationale: Normal saline is an isotonic solution that is commonly used for initial fluid resuscitation in cases of blood loss or dehydration. While Lactated Ringer's is also an option, NS is often preferred in emergencies due to its simplicity.

Question 49

# Lactated Ringer's Solution What is Lactated Ringer's tonicity, compostions, & uses?

Answer 49

Tonicity: Isotonic - meaning it has a similar concentration of dissolved particles as the body's extracellular fluid (ECF). Composition: Contains sodium, potassium, chloride, calcium, and lactate. The lactate is metabolized by the liver into bicarbonate, which helps buffer acidity. Use Cases: * Expanding ECF: Used to expand the ECF volume, such as in situations involving fluid loss due to surgery, burns, and gastrointestinal (GI) losses (vomiting, diarrhea). * Electrolyte Replacement: Provides electrolytes, helping to replenish those lost in various conditions.

Question 50

# Lactated Ringer's Solution What are some contraindication of Lactated Ringer's Solution? | 3

Answer 50

1. Liver Problems: Contraindicated in patients with liver impairment as they may have difficulty metabolizing lactate into bicarbonate. 2. Hyperkalemia: Contraindicated in patients with high potassium levels as LR contains potassium. 3. Severe Hypovolemia: Use with caution in severe hypovolemia as rapid infusion can lead to electrolyte imbalances.

Question 51

# Lactated Ringer's Solution What are some important considerations for Lactated Ringer's Solution and what should you monitor?

Answer 51

Fluid Resuscitation: LR is often used for fluid resuscitation in trauma and burn patients. Metabolic Alkalosis: While it can help buffer acidity, excessive administration can lead to metabolic alkalosis. Monitoring: When administering LR, it's essential to monitor for: * Fluid Overload: Signs include edema (swelling), crackles in the lungs, jugular venous distention (JVD), and rapid weight gain. * Electrolyte Imbalances: Especially potassium and calcium, as LR contains these electrolytes. * Acid-Base Balance: Monitor for signs of metabolic alkalosis.

Question 52

Which of the following statements accurately describe Lactated Ringer's (LR) solution? (Select all that apply.) A. It is a hypotonic solution. B. It contains sodium, potassium, chloride, calcium, and lactate. C. It is used to expand the extracellular fluid volume. D. It is contraindicated in patients with liver problems. E. It can lead to hyperkalemia.

Answer 52

B, C, D Rationale: LR is isotonic, not hypotonic. It is contraindicated in hyperkalemia as it contains potassium.

Question 53

A patient with severe burns requires intravenous fluid replacement. Which type of IV fluid would be MOST appropriate to administer initially? A. 0.45% Normal Saline (1/2 NS) B. D5W (5% Dextrose in Water) C. 0.9% Normal Saline (NS) D. Lactated Ringer's (LR)

Answer 53

D Rationale: LR is often preferred in burn patients due to its balanced electrolyte composition and its lactate content, which can help buffer metabolic acidosis often seen in burn injuries.

Question 54

# Hypertonic IV Fluids What are the osmolality, fluid shift, and key monitoring for hypertonic IV fluids?

Answer 54

Osmolality: Hypertonic solutions have a higher osmolality (concentration of dissolved particles) compared to plasma (blood). Fluid Shift: Due to this higher concentration, they draw water out of the cells into the extracellular fluid (ECF). This leads to cell shrinkage and expansion of the ECF volume and requires frequent monitoring. Key Monitoring: * Blood Pressure: Can increase due to the increased fluid volume in the ECF. * Lung Sounds: Monitor for signs of fluid overload or pulmonary edema as fluid is drawn into the vascular space. * Serum Sodium Levels: Hypertonic solutions can significantly impact sodium levels, so close monitoring is crucial.

Question 55

# Hypertonic IV Fluids What are some uses of hypertonic IV fluids?

Answer 55

Hypertonic solutions are typically used in specific situations, such as: * Severe Hyponatremia (low sodium levels): To quickly increase sodium levels. * Cerebral Edema (swelling in the brain): To draw fluid out of the brain tissue and reduce swelling. ## Footnote Administration: These solutions should be administered cautiously and usually via a central line due to the risk of vein irritation. Rate of Infusion: The infusion rate is carefully controlled to avoid rapid fluid and electrolyte shifts.

Question 56

Which of the following statements are correct regarding hypertonic IV fluids? (Select all that apply.) A. They have a lower osmolality than plasma. B. They cause water to move from the ICF to the ECF. C. They can be used to treat severe hyponatremia. D. They can cause cells to shrink. E. They require frequent monitoring of blood pressure, lung sounds, and serum sodium levels.

Answer 56

B, C, D, E

Question 57

A patient is receiving a hypertonic saline solution for severe hyponatremia. Which of the following assessments should the nurse prioritize during the infusion? A. Checking the patient's blood glucose level. B. Assessing the patient's neurological status. C. Monitoring the patient's urine output. D. Assessing the patient's skin turgor.

Answer 57

B Rationale: Changes in mentation can be a sign of rapid shifts in electrolytes and fluid balance, including cerebral edema. Therefore, neurological assessment is the priority.

Question 58

# D5 1/2 NS (5% Dextrose in 0.45% Normal Saline) What is D5 1/2 NS's tonicity, compostions, & uses?

Answer 58

Tonicity: Technically, it's initially hypertonic due to the dextrose, but the dextrose is quickly metabolized, leaving a hypotonic solution (0.45% NS). So, the net effect is hypotonic. Components: Contains dextrose (sugar) and 0.45% normal saline (half-strength saline). Uses: * Common Maintenance Fluid: Often used for maintenance IV fluids, providing hydration, calories, and some electrolytes. * Replaces Fluid Loss: Can be used to replace fluid losses, but it's important to consider the electrolyte content in relation to the patient's specific needs. * Potassium Chloride (KCl) Addition: Potassium chloride (KCl) is often added to D5 1/2 NS to meet the patient's daily potassium needs or to replace potassium deficits.

Question 59

# D5 1/2 NS (5% Dextrose in 0.45% Normal Saline) What are some important considerations for D5 1/2 NS and what should you monitor?

Answer 59

Dextrose Metabolism: The dextrose provides calories and is quickly metabolized, leaving free water that dilutes the extracellular fluid. Electrolyte Content: 0.45% NS provides sodium and chloride, but in lower amounts than normal saline. It may not be sufficient for significant sodium losses. Monitoring: * Fluid Overload: Signs include edema, crackles in the lungs, jugular venous distention (JVD), and rapid weight gain. * Electrolyte Imbalances: Especially sodium, potassium, and chloride. * Hyperglycemia: Due to the dextrose content. * Changes in Mental Status: Can be related to either electrolyte imbalances or hydration status.

Question 60

Which of the following statements are correct regarding D5 1/2 NS? (Select all that apply.) A. It is initially hypotonic. B. It is commonly used for maintenance fluids. C. It provides calories. D. It can be used to replace fluid losses. E. Potassium chloride (KCl) is often added to it.

Answer 60

B, C, D, E

Question 61

A patient is receiving D5 1/2 NS with KCl. The nurse notes that the patient's potassium level is 5.8 mEq/L. What is the nurse's BEST action? A. Increase the IV flow rate. B. Hold the current IV infusion and notify the healthcare provider. C. Administer a potassium-wasting diuretic. D. Document the finding and continue the infusion as prescribed.

Answer 61

B Rationale: A potassium level of 5.8 mEq/L is considered high (hyperkalemia). The nurse should hold the IV infusion containing KCl and notify the provider.

Question 62

# Colloids What is the definition of colloids, what is it's effect on coagulation?

Answer 62

Definition: Colloids are intravenous solutions containing large molecules that do not readily cross capillary membranes. They primarily stay within the vascular space (blood vessels). Effect on Coagulation: All colloids affect blood coagulation to some extent by interfering with coagulation factor VII. This is an important consideration, especially in patients with bleeding disorders.

Question 63

# Colloids What are some types of colloids?

Answer 63

Human Plasma Products: * Albumin: A protein that helps maintain oncotic pressure. Available in various concentrations (e.g., 5%, 25%). * Fresh Frozen Plasma (FFP): Contains clotting factors and plasma proteins. Used to treat clotting disorders or replace multiple clotting factors. * Blood: Whole blood or packed red blood cells (PRBCs) are also considered colloids due to their cellular components. Semisynthetics: * Dextran: A polysaccharide that expands plasma volume. Different molecular weights are available. * Starches (e.g., Hespan, Voluven): Also used for volume expansion.

Question 64

# Colloids What are some uses of colloids? How are they administered?

Answer 64

Uses: Colloids are used to treat conditions involving fluid volume deficits or low oncotic pressure, such as: * Shock (hypovolemic, septic) * Severe burns * Liver failure * Kidney disease Administration: Colloids are generally administered intravenously. The rate of infusion depends on the specific product and the patient's condition.

Question 65

# Colloids What should the nurse monitor for with colloids?

Answer 65

* Fluid Overload: Signs include edema, crackles in the lungs, jugular venous distention (JVD), and rapid weight gain. * Allergic Reactions: Especially with dextran and starches. * Coagulation Disorders: Due to the potential effect on coagulation. * Electrolyte Imbalances: Fluid shifts can affect electrolyte concentrations.

Question 66

Which of the following statements are correct regarding colloids? (Select all that apply.) A. They readily cross capillary membranes. B. They increase oncotic pressure in the blood. C. They can interfere with blood coagulation. D. Albumin is an example of a colloid. E. They cause fluid to shift from the interstitial space to the vascular space.

Answer 66

B, C, D, E

Question 67

A patient with a known history of bleeding disorder is ordered to receive dextran. Which action by the nurse is MOST appropriate? A. Administer the dextran as prescribed. B. Question the order with the healthcare provider. C. Monitor the patient's blood pressure closely. D. Ensure that the patient has a patent IV access.

Answer 67

B Rationale: Dextran can interfere with coagulation, so it may not be appropriate for a patient with a bleeding disorder. The nurse should question the order with the healthcare provider.

Question 68

# Potassium Imbalances What are some cause of hypokalemia?

Answer 68

Vomiting Gastric suction Prolonged diarrhea Diuretics and steroids Inadequate intake Large urine output

Question 69

# Potassium Imbalances What are some cause of hyperkalemia?

Answer 69

Cared Cellular Movement of K from ICF to ECF (burns) Adrenal Insufficiency with Addison's Disease Renal Failure Drugs (potassium sparing diuretics)

Question 70

A patient with hypokalemia is ordered to receive IV potassium chloride (KCl). Which action by the nurse is the HIGHEST priority? A. Administer the KCl via a peripheral IV line. B. Infuse the KCl at a rate of 40 mEq/hr. C. Monitor the patient for signs of phlebitis at the IV site. D. Assess the patient's cardiac rhythm.

Answer 70

D Rationale: Cardiac arrhythmias are a potential complication of both hypokalemia and hyperkalemia. Monitoring the cardiac rhythm is the priority when administering IV KCl. KCl should be administered via a central line when possible due to vein irritation and should be infused slowly (typically no more than 10-20 mEq/hr unless in a critical situation).

Question 71

# Potassium Imbalances: Signs and Symptoms What are some S/S of hypokalemia?

Answer 71

A Sic Walt Alkalosis Shallow Respirations Irritability Confusion & Drowsiness Weakness & Fatigue Arrhythmias Lethargy Thready Pulse

Question 72

# Potassium Imbalances: Signs and Symptoms What are some S/S of hyperkalemia?

Answer 72

Murder Muscle Weakness Urine output little or none Respiratory Failure (due to muscle weakness) Decreased cardiac contractility (weak pulse/low HR) Early: muscle twitches/cramps Rhythm changes: Tall peaked T waves, prolonged QT interval

Question 73

A patient's potassium level is 6.2 mEq/L. Which of the following EKG changes would the nurse expect to see? A. Flattened T waves B. Peaked T waves C. Prominent U waves D. Prolonged PR interval

Answer 73

B Rationale: Peaked T waves are a characteristic EKG finding in hyperkalemia.

Question 74

# Nursing Management of Hypokalemia What are 2 forms of potassium replacement?

Answer 74

Oral: For mild to moderate hypokalemia. Potassium supplements are available in various forms (e.g., tablets, liquids, powders). IV: For more severe hypokalemia or when oral intake is not feasible. Important: IV potassium must be diluted and administered slowly via an infusion pump to prevent cardiac arrhythmias. It can cause vein irritation, so central line administration is preferred if possible. ## Footnote Dietary Measures: Encourage consumption of potassium-rich foods (e.g., bananas, oranges, raisins, apricots, spinach, potatoes).

Question 75

# Nursing Management of Hypokalemia What should be monitored with patients with hypokalemia?

Answer 75

Renal Function: Essential to ensure the kidneys can excrete excess potassium. Impaired renal function increases the risk of hyperkalemia with potassium replacement. Cardiac Status: Monitor for cardiac arrhythmias (irregular heart rhythms) as hypokalemia can affect cardiac conduction. Digitalis Toxicity: Hypokalemia increases the risk of digitalis toxicity in patients taking digoxin (a heart medication). Monitor for signs of toxicity (e.g., nausea, vomiting, visual disturbances).

Question 76

# Nursing Management of Hyperkalemia What are some medications used to treat hyperkalemia? ## Footnote Dietary Restriction: Limit intake of potassium-rich foods. Dialysis: May be necessary in patients with renal failure and severe hyperkalemia.

Answer 76

Sodium Polystyrene Sulfonate (Kayexalate): A cation exchange resin that binds potassium in the gastrointestinal tract, promoting its excretion in the feces. Administered orally or rectally. Calcium Gluconate: Administered IV in emergency situations to protect the heart from the effects of hyperkalemia. It does not lower potassium levels but stabilizes the cardiac membrane. Sodium Bicarbonate: Administered IV to temporarily shift potassium into cells. It also helps correct metabolic acidosis, which often accompanies hyperkalemia. Regular Insulin and Dextrose: Insulin promotes the uptake of glucose by cells, and potassium follows glucose into the cells, thus lowering serum potassium levels. Dextrose is given to prevent hypoglycemia. Diuretics (e.g., Furosemide): Increase potassium excretion by the kidneys.

Question 77

# Nursing Management of Hyperkalemia What are should be monitored with patients with hyperkalemia?

Answer 77

ECG: Closely monitor the ECG for changes associated with hyperkalemia (peaked T waves, widened QRS complex). Potassium Levels: Regularly monitor serum potassium levels to assess the effectiveness of treatment. Renal Function: Assess renal function to ensure the kidneys can excrete potassium. Acid-Base Balance: Monitor for metabolic acidosis.

Question 78

A nurse is caring for a patient with hypokalemia. Which of the following interventions should be included in the plan of care? (Select all that apply.) A. Administer IV potassium chloride (KCl) bolus. B. Encourage consumption of potassium-rich foods. C. Monitor the patient's cardiac rhythm. D. Administer a potassium-sparing diuretic. E. Assess the patient's renal function. F. Educate the patient about the signs and symptoms of hyperkalemia.

Answer 78

B, C, E Rationale: IV KCl should never be administered as a bolus due to the risk of cardiac arrest. Potassium-sparing diuretics can worsen hypokalemia. Patient education about hyperkalemia is important, but the question focuses on interventions for hypokalemia.

Question 79

A patient with hyperkalemia has a potassium level of 6.5 mEq/L and is exhibiting muscle twitching and paresthesia. Which of the following interventions should the nurse prioritize? A. Administer sodium polystyrene sulfonate (Kayexalate). B. Administer calcium gluconate. C. Restrict dietary potassium intake. D. Monitor the patient's ECG.

Answer 79

B Rationale: While all options are important, the patient is exhibiting neuromuscular symptoms of hyperkalemia, indicating potential cardiac involvement. Calcium gluconate is the priority as it protects the heart from the effects of hyperkalemia.

Question 80

# Sodium Imbalances What is the normal range for sodium?

Answer 80

136 mEq/L - 145 mEq/L

Question 81

# Sodium Imbalances What are some causes of hyponatremia?

Answer 81

Vomiting Diuretics Excessive administration of dextrose and water IVs Burns Wound drainage Excessive water intake Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Elderly (unable to excrete free water) Fasting diets Nasogastric suction

Question 82

# Sodium Imbalances What are some causes of hypernatremia?

Answer 82

Model Medications; Meals (too much sodium intake) Osmotic diuretics Diabetes insidious Excess H2O loss Low H2O intake

Question 83

A patient with hypernatremia has a sodium level of 158 mEq/L and is exhibiting confusion and agitation. Which action by the nurse is the HIGHEST priority? A. Administering a hypotonic IV solution. B. Restricting dietary sodium. C. Ensuring patient safety due to altered mental status. D. Monitoring urine output.

Answer 83

C Rationale: The patient's altered mental status poses an immediate safety risk. Ensuring patient safety is the priority.

Question 84

# Signs and Symptoms of Sodium Imbalances What are some S/S of hyponatremia?

Answer 84

Salt Loss Stupor/Coma Anorexia Lethargy Tendon reflexes decreased Limp Muscles Orthostatic hypotension Seizures Stomach cramping

Question 85

# Signs and Symptoms of Sodium Imbalances What are some S/S of hypernatremia?

Answer 85

Fried Salt Flushed skin Restless, irritable, anxious, confused Increased blood pressure & fluid retention Edema (peripheral & pitting) Decreased Urine output & dry mouth Skin Flushed Agitation Low grade fever Thirst

Question 86

# Nursing Management of Hyponatremia What are the dietary management and IV fluid management of hyponatremia?

Answer 86

Dietary Management: Include sodium-enriched foods in the diet (e.g., beef broth, tomato juice). However, dietary sodium alone may not be sufficient to correct hyponatremia in many cases. Intravenous Fluids: * Lactated Ringer's (LR): May be used for replacement in some cases, but it's important to consider the patient's overall electrolyte status. * High Concentration of 0.9% Normal Saline: Hypertonic saline (e.g., 3% NaCl) may be used in severe cases or when rapid correction is needed, but it requires careful monitoring due to the risk of fluid overload and rapid sodium correction. ## Footnote Fluid Restriction: May be implemented if the hyponatremia is mild and caused by excess water (e.g., in SIADH).

Question 87

# Nursing Management of Hyponatremia What are somethings to monitor with patients with hyponatremia?

Answer 87

Intake and Output (I&O): Essential to track fluid balance. Daily Weights: Changes in weight can indicate fluid shifts. Serum Sodium Levels: Regular monitoring is crucial to assess the effectiveness of treatment and prevent overcorrection.

Question 88

# Nursing Management of Hypernatremia What are the dietary management and IV fluid management of hypernatremia?

Answer 88

Dietary Management: Decrease sodium in the diet ntravenous Fluids: * Hypotonic IV Solutions: 0.3% Normal Saline, 0.45% Normal Saline, or Dextrose 5% in water (D5W) are used to gradually replace water deficits and lower sodium levels.

Question 89

# Nursing Management of Hypernatremia What are somethings to monitor with patients with hyponatremia?

Answer 89

Daily Weights: To monitor fluid status. Serum Sodium Levels: Regular monitoring is crucial to assess the effectiveness of treatment and prevent overcorrection.

Question 90

# Calcium Imbalances What is the normal range for calcium?

Answer 90

9.0 mg/dL - 10.5 mg/dL

Question 91

# Calcium Imbalances What are some causes of hypocalcemia?

Answer 91

Renal insufficiency Malnutrition Low magnesium level Pancreatitis Hypoparathyroidism High phosphate level Loop diuretics Chronic alcohol use Post-thyroid surgery

Question 92

# Calcium Imbalances What are some causes of hypercalcemia?

Answer 92

Hyperparathyroidism Excess dairy intake Steroids and loop diuretics use Inadequate intake (This seems counterintuitive and likely refers to inadequate fluid intake leading to concentrated calcium levels.) Calcium-containing antacids (Tums) Thiazide diuretics Vitamin A or D overdose Immobility

Question 93

A patient with hypocalcemia is exhibiting muscle spasms and tetany. Which action by the nurse is the HIGHEST priority? A. Administering oral calcium supplements. B. Monitoring the patient's cardiac rhythm. C. Assessing the patient's Chvostek's and Trousseau's signs. D. Preparing for IV calcium administration.

Answer 93

B Rationale: Muscle spasms and tetany can progress to seizures or laryngospasm, which can compromise the patient's airway and breathing. Therefore, monitoring the cardiac rhythm for potential arrhythmias is the priority.

Question 94

A patient with hypercalcemia is ordered to receive IV fluids and furosemide (a loop diuretic). Which of the following outcomes would indicate that the treatment is effective? A. Increased serum calcium level. B. Decreased urine output. C. Improved muscle strength. D. Increased urine calcium excretion.

Answer 94

D Rationale: The goal of treatment is to increase calcium excretion in the urine, thus lowering the serum calcium level.

Question 95

# Signs and Symptoms of Calcium Imbalances What are some S/S of hypocalcemia?

Answer 95

Cats Convulsions Arrhythmias Tetany Spasms & Stridor

Question 96

# Signs and Symptoms of Calcium Imbalances What are some S/S of hypercalcemia?

Answer 96

BACKME Bone pain Arrhythmias Cardiac Arrest Kidney Stones Muscle Weakness Excessive Urination

Question 97

# Nursing Management of Hypocalcemia What are some medications used for the management of hypocalcemia?

Answer 97

IV Calcium Gluconate or Calcium Chloride: Used for acute symptomatic hypocalcemia. Calcium gluconate is generally preferred over calcium chloride due to a lower risk of tissue necrosis if extravasation occurs. Administer slowly to avoid cardiac arrhythmias. Vitamin D Supplements: Enhance calcium absorption from the gut. May be given orally or IM.

Question 98

# Nursing Management of Hypocalcemia What are some additional management of hypocalcemia? (not medication)

Answer 98

Dietary Management: Increase calcium intake through diet (dairy products, leafy green vegetables, fortified foods). Diuretic Considerations: If the patient is on loop diuretics (which can increase calcium excretion), the provider may consider switching to thiazide diuretics (which can decrease calcium excretion). Airway Management: Laryngeal stridor (a high-pitched whistling sound during breathing) can occur due to laryngospasm (spasm of the vocal cords) in severe hypocalcemia. Maintaining a patent airway is crucial. Seizure Precautions: Hypocalcemia can increase the risk of seizures. Implement seizure precautions as needed (padded side rails, oxygen and suction at bedside).

Question 99

# Nursing Management of Hypercalcemia What are some medications used to manage hypercalcemia?

Answer 99

Medications: * Calcitonin: A hormone that inhibits bone resorption and increases calcium excretion by the kidneys. It acts quickly but its effect is transient. * Loop Diuretics (e.g., Furosemide): Increase calcium excretion by the kidneys. * Bisphosphonates (e.g., Pamidronate, Zoledronic Acid): Inhibit bone resorption and are considered the gold standard for treating hypercalcemia, especially when caused by malignancy. Medication Discontinuation: Stop any medications that contribute to hypercalcemia (e.g., calcium supplements, thiazide diuretics, some antacids).

Question 100

# Nursing Management of Hypercalcemia What are some additional management of hypercalcemia? (not medication)

Answer 100

Dietary Management: A low-calcium diet may be recommended. Hydration: Encourage oral intake of 3000-4000 mL of fluids daily to dilute calcium and prevent kidney stone formation. IV hydration with isotonic saline may be needed in some cases. Dialysis: May be necessary in severe cases or in patients with renal impairment. Mobility: Encourage mobilization as tolerated. Immobility can exacerbate hypercalcemia by promoting bone resorption.

Question 101

A patient is receiving IV calcium gluconate for symptomatic hypocalcemia. The nurse notes that the patient's heart rate has decreased from 80 to 60 beats per minute. Which of the following actions should the nurse take FIRST? A. Stop the infusion of calcium gluconate. B. Notify the healthcare provider. C. Assess the patient's blood pressure. D. Document the finding and continue to monitor.

Answer 101

A Rationale: Bradycardia can be a sign of calcium toxicity. The nurse should stop the infusion first and then notify the provider.

Question 102

# Magnesium Imbalances What is the normal magnesium range?

Answer 102

1.3 mEq/L - 2.1 mEq/L

Question 103

# Magnesium Imbalances What are some causes of hypomagnesemia?

Answer 103

Alcoholism Gastrointestinal suction Diarrhea Intestinal fistulas Uncontrolled diabetes mellitus Malabsorption syndrome Proton-pump inhibitor (PPI) therapy (e.g., omeprazole, esomeprazole, pantoprazole)

Question 104

# Magnesium Imbalances What are some causes of hypermagnesemia?

Answer 104

Renal failure IV administration of magnesium Antacids and laxatives (especially those containing magnesium) Hypothyroidism Metastatic bone disease

Question 105

A patient with hypomagnesemia is exhibiting muscle tremors and tetany. Which action by the nurse is the HIGHEST priority? A. Administering oral magnesium supplements. B. Monitoring the patient's cardiac rhythm. C. Assessing the patient's deep tendon reflexes. D. Preparing for IV magnesium sulfate administration.

Answer 105

B Rationale: Muscle tremors and tetany can progress to seizures or laryngospasm, which can compromise the patient's airway and breathing. Therefore, monitoring the cardiac rhythm for potential arrhythmias is the priority.

Question 106

A patient with hypermagnesemia is ordered to receive IV calcium gluconate. Which of the following outcomes would indicate that the medication is effective? A. Increased magnesium level. B. Improved muscle strength. C. Increased heart rate. D. Increased urine output.

Answer 106

C Rationale: Calcium gluconate antagonizes the cardiac effects of hypermagnesemia, particularly bradycardia. Therefore, an increased heart rate would indicate that the medication is effective.

Question 107

A patient with a history of alcohol abuse is admitted to the hospital. The nurse anticipates which of the following magnesium-related abnormalities? A. Hypermagnesemia due to increased magnesium intake. B. Hypomagnesemia due to malnutrition and malabsorption. C. Normal magnesium levels as long as the patient is hydrated. D. Fluctuating magnesium levels depending on the patient's oral intake.

Answer 107

B Rationale: Alcohol abuse is a common cause of hypomagnesemia due to poor dietary intake, malabsorption, and increased renal excretion of magnesium.

Question 108

# Signs and Symptoms of Magnesium Imbalances What are some S/S of hypomagnesemia?

Answer 108

Starved Seizures Tetany Anorexia & arrhythmias Rapid heart rate Vomiting Emotional liability Deep tendon reflexes increased

Question 109

# Signs and Symptoms of Magnesium Imbalances What are some S/S of hypermagnesemia?

Answer 109

LVDS Low everything (BP, HR, RR, Reflexes) Vasodilation Diaphoresis Skeletal Muscle Weakness

Question 110

# Nursing Management of Hypomagnesemia What are dietary management and magnesium replacement used to treat hypomagnesemia?

Answer 110

Dietary Management: Increase dietary intake of magnesium-rich foods (e.g., green leafy vegetables, nuts, legumes, whole grains). Magnesium Replacement: * Oral: For mild to moderate hypomagnesemia. Magnesium oxide is a common oral supplement. * IV: For severe hypomagnesemia or when oral intake is not feasible. Magnesium sulfate is the typical IV form. Administer slowly and cautiously via an infusion pump due to the risk of hypotension, cardiac arrest, and respiratory arrest. Rapid administration can cause these complications. ## Footnote Seizure Precautions: Hypomagnesemia can increase the risk of seizures. Implement seizure precautions as needed (padded side rails, oxygen and suction at bedside).

Question 111

# Nursing Management of Hypomagnesemia What are somethings to monitor hypomagnesemia?

Answer 111

Vital Signs: Monitor for hypotension, especially during IV magnesium administration. Cardiac Rhythm: Monitor for cardiac arrhythmias (irregular heart rhythms) as hypomagnesemia can affect cardiac conduction. Neurological Status: Assess for changes in mental status, tremors, or tetany. Deep Tendon Reflexes: Check for hyperreflexia (increased reflexes) which is a sign of hypomagnesemia.

Question 112

# Nursing Management of Hypermagnesemia What are some managements/treatments for hypermagnesemia? ## Footnote Discontinue Magnesium: Stop any magnesium-containing medications (e.g., supplements, antacids, laxatives).

Answer 112

Support Ventilation: Monitor respiratory status closely and provide support as needed, as hypermagnesemia can cause respiratory depression. Dietary Management: Educate the patient about reducing intake of magnesium-rich foods. Medications: IV Calcium Gluconate: Administered to antagonize the effects of excess magnesium on the cardiac muscle. It does not lower magnesium levels but stabilizes the cardiac membrane. Diuretics (e.g., Furosemide): Increase magnesium excretion by the kidneys. Dialysis: May be necessary in patients with renal impairment and severe hypermagnesemia.

Question 113

# Nursing Management of Hypermagnesemia What are somethings to monitor for with hypermagnesemia?

Answer 113

Cardiac Rhythm: Closely monitor the ECG for bradycardia (slow heart rate) and heart block. Vital Signs: Monitor for hypotension and respiratory depression. Neurological Status: Assess for drowsiness, lethargy, confusion, and decreased deep tendon reflexes. Urine Output: Monitor urine output to ensure adequate renal function and magnesium excretion.

Question 114

A patient with hypermagnesemia has a magnesium level of 3.0 mEq/L and is exhibiting drowsiness and decreased deep tendon reflexes. Which of the following interventions should the nurse prioritize? A. Administering oral magnesium supplements. B. Monitoring the patient's cardiac rhythm. C. Assessing the patient's respiratory rate and depth. D. Encouraging increased fluid intake.

Answer 114

C Rationale: Drowsiness and decreased reflexes can indicate central nervous system depression and potential respiratory depression, which is the most immediate threat to the patient.

Question 115

A patient is receiving IV magnesium sulfate for hypomagnesemia. The nurse notes that the patient's blood pressure has decreased from 140/90 to 110/70 mm Hg. Which of the following actions should the nurse take FIRST? A. Increase the IV magnesium sulfate rate. B. Stop the infusion of magnesium sulfate. C. Notify the healthcare provider. D. Assess the patient's respiratory rate.

Answer 115

B Rationale: Hypotension is a potential side effect of IV magnesium sulfate. The nurse should stop the infusion first and then notify the provider.

Question 116

# Phosphate Imbalances What is the normal range for phosphate?

Answer 116

3.0 mg/dL - 4.5 mg/dL

Question 117

# Phosphate Imbalances What are some causes of hypophosphatemia

Answer 117

Malabsorption syndromes Chronic diarrhea Malnutrition, Vitamin D deficiency Parenteral nutrition (TPN) Chronic alcohol use Phosphate-binding antacids

Question 118

# Phosphate Imbalances What are some causes of hyperphosphatemia

Answer 118

Renal failure Phosphate enemas (Fleet) Phosphate-containing laxatives (e.g., bowel prep for colonoscopy like OsmoPrep) Sickle cell anemia Rhabdomyolysis (muscle breakdown)

Question 119

A patient with hypophosphatemia is exhibiting muscle weakness and shallow respirations. Which action by the nurse is the HIGHEST priority? A. Administering oral phosphate supplements. B. Monitoring the patient's cardiac rhythm. C. Assessing the patient's neurological status. D. Preparing for IV phosphate replacement.

Answer 119

B Rationale: Shallow respirations indicate potential respiratory muscle weakness, which can compromise the patient's oxygenation. Therefore, monitoring the cardiac rhythm for potential arrhythmias is the priority.

Question 120

A patient with hyperphosphatemia is ordered to receive calcium carbonate (a phosphate-binding antacid). Which of the following outcomes would indicate that the medication is effective? A. Increased serum phosphate level. B. Decreased serum calcium level. C. Increased urine output. D. Decreased serum phosphate level.

Answer 120

D Rationale: Calcium carbonate binds to phosphate in the GI tract, preventing its absorption and thus lowering serum phosphate levels.

Question 121

# Signs and Symptoms of Phosphate Imbalances What are some S/S of hypophosphatemia?

Answer 121

ALOW Arrhythmias Loss of appetite Osteoporosis Weakness, fatigue

Question 122

# Signs and Symptoms of Phosphate Imbalances What are some S/S of hyperphosphatemia?

Answer 122

MADS Muscle Spasms & tetany Arrhythmias Dry Nails Seizures

Question 123

# Nursing Management of Hypophosphatemia What are some dietary management and phosphate supplements?

Answer 123

Dietary Management: Increase dairy intake (a good source of phosphorus). Phosphate Supplements: * Oral: Available in various forms. * IV: Sodium phosphate or potassium phosphate may be given for severe cases. Important: - Monitor serum calcium and phosphate levels every 6 to 12 hours during IV administration. - During IV therapy, monitor for signs of hypocalcemia (due to the inverse relationship between phosphate and calcium), hyperkalemia (if potassium phosphate is used), hypotension, and dysrhythmias. Administer slowly and cautiously.

Question 124

# Nursing Management of Hyperphosphatemia What are some dietary, medications, and other managements of hyperphosphatemia? ## Footnote Treat Underlying Condition: Address the underlying cause of hyperphosphatemia (e.g., renal failure).

Answer 124

Dietary Management: Restrict intake of foods high in phosphate, such as dairy products. Medications: * Calcium Carbonate: A phosphate binder that helps prevent the absorption of phosphate from the GI tract. Administer with meals. * Loop Diuretics: May be used to promote phosphate excretion by the kidneys. Dialysis: May be necessary in severe cases, especially in patients with renal failure. ## Footnote Correct Hypocalcemia: If hypocalcemia is present (due to the inverse relationship with phosphate), institute measures to correct calcium levels (e.g., calcium supplements, vitamin D).

Question 125

A patient with hyperphosphatemia is exhibiting numbness and tingling in the extremities and muscle cramps. Which of the following interventions should the nurse prioritize? A. Administering calcium carbonate. B. Restricting dietary phosphate. C. Monitoring the patient's cardiac rhythm. D. Assessing the patient's respiratory status.

Answer 125

C Rationale: The patient's neuromuscular symptoms suggest potential hypocalcemia (due to the inverse relationship with phosphate), which can lead to cardiac arrhythmias. Monitoring the cardiac rhythm is the priority.

Question 126

A patient is receiving IV sodium phosphate for hypophosphatemia. The nurse notes that the patient's calcium level has decreased from 8.5 mg/dL to 7.8 mg/dL. Which of the following actions should the nurse take FIRST? A. Increase the IV phosphate rate. B. Stop the infusion of sodium phosphate. C. Notify the healthcare provider. D. Assess the patient's neurological status.

Answer 126

B Rationale: A decrease in calcium during phosphate replacement can indicate developing hypocalcemia. The nurse should stop the infusion first and then notify the provider.

Question 127

What are the mm for each grade of edema (1+, 2+, 3+, 4+)?

Answer 127

1+: 2 mm 2+: 4 mm 3+: 6 mm 4+: 8 mm

Question 128

What is Chvostek's sign? (Hypocalcemia)

Answer 128

Contraction of facial muscles in response to a light tap over the facial nerve in front of the ear

Question 129

What is Trousseau's signs?

Answer 129

Carpal spasm induced by inflating BP cuff above the systolic pressure for a few minutes