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FINAL exam - A&E CK > Fluid and Electrolytes and Dysphagia > Flashcards

Fluid and Electrolytes and Dysphagia Flashcards

1
Q

An older adult client is admitted w/ dehydration. Which nursing assessment data identifies that the client is at risk for falling?

a. dry oral mucous membranes
b. orthostatic BP changes
c. pulse rate of 72 bpm and bounding
d. serum potassium level of 4.0 mEq/L

A

b. orthostatic BP changes

to test for this, you take the BP in all different positions–as appropriate

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2
Q

what’s the AVG normal daily input and output?

A

2200-2700mL

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3
Q

Which situation can cause a client to experience “INSENSIBLE (not visible) water loss”? (Select all that apply).
a. Diarrhea

b. Dry, hot weather
c. Fever
d. Increased respiratory rate
e. Nausea
f. Mechanical ventilation

A

a. Diarrhea
b. Dry, hot weather
c. Fever
d. Increased respiratory rate (when you take a deep breath, there is water loss via evaporation when you expire)
f. Mechanical ventilation (this could lead to a person hyperventilation which puts them AT RISK FOR DEHYDRATION)

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4
Q

What are the different factors that play into the thirst mechanism?

A 
Decreased plasma volume
Inc plasma osmolality
Angiotensin II AND III
Dry pharyngeal mucous membranes
Psychological factors (children, dementia, elderly)
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5
Q

ANP (atrial natriuretic peptide) opposes the effects of which hormone?

A

aldosterone (also ADH)

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6
Q

which 3 hormones play important roles in electrolyte and fluid regulation?

A

ADH
Aldosterone
ANP

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7
Q

what triggers the release of ANP?

A

fluid overload, increased ECV, congestion (when the atria of heart are STRETCHED)

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8
Q

What are the s/s of dehydration

A 
Decreased skin turgor (tenting)
Thirst
Dry mucus membrane
Confusion
Decreased urine output
Hypotension
Tachycardia
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9
Q

intracellular fluid makes up approx what amt of total body fluids?

A

2/3

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10
Q

How to diagnose HYPOnatremia

A

blood sodium level less than 135 mEq/L
(note: this is “relative”. It can either be bc the blood is diluted (e.g. giving too much hypotonic fluids or water intoxication) or because they are losing too much sodium (e.g. vomiting or diarrhea)

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11
Q

What’s the primary Extracellular Fluid (ECF) cation

A

sodium (Na+)

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12
Q

What’s the normal sodium levels

A

Sodium (135-145 mEq/L)

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13
Q

How to diagnose for HYPERnatremia?

A

blood sodium level above 145 mEq/L

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14
Q

Hypernatremia can be caused by two issues:

A
  1. sodium gain (e.g. inappropriate administration of hypertonic fluids, or Cushing syndrome)
  2. water loss is greater than the relative sodium loss (e.g. diabetes insipidus or lack of ADH)
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15
Q

Which client is at greatest risk for hypernatremia?

A 17 year-old with a serum blood glucose of 189 mg/dL

B 30 year-old on a low-salt diet

C 42 year-old receiving hypotonic fluids

D 54 year-old who is sweating profusely

A

54 year-old who is sweating profusely (he is eliminating more fluid relative to Na+)

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16
Q

inappropriate administration of HYPERtonic fluids can potentially lead to

A

hypernatremia

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17
Q

inappropriate administration of HYPOtonic fluids can potentially lead to

A

hyponatremia

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18
Q

what is “normal saline”?

A

0.9% NaCl

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19
Q

What is the normal Potassium level?

A

3.5-5.0 mEq/L

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20
Q

Functions of potassium

A

Transmits nerve impulses & cardiac impulses

Helps maintain intracellular water balance

Increased with poor kidney function

Decreased with excessive urination, diarrhea, vomiting

Imbalances cause cardiac problems

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21
Q

A client is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first?

a. Blood pressure
b. Pulse
c. Respirations
d. Temperature

A

Think of ABC’s!
c. Respirations
(airway comes first)

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22
Q

The health care provider writes orders for a client who is admitted with a serum potassium level of 6.9 mEq/L. What does the nurse implement first?

a. Administer sodium polystrene sulfonate (Kayexalate) orally
b. Ensure that a potassium-restricted diet is ordered
c. Place the client on a cardiac monitor
d. Teach the client about foods that are high in potassium

A

c. Place the client on a cardiac monitor

note that choice A would be 2nd priority bc the drub “Kayexalate” helps to eliminate K+ from the system

23
Q

hematocrit normal is always ______ that of hemoglobin (10-14 is normal)

A

3 times

24
Q

normal chloride value

A

98-106

25
Q

normal potassium value

A

3.5-5.0

26
Q

normal pH value

A

7.35-7.45

27
Q

normal pCO2 value

A

35-45

28
Q

normal HCO3 (bicarb) value

A

22-26

29
Q

A PT is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies. “She was sleeping so well, I didn’t want to wake her to get her weight.” How does the nurse respond?

a. “Good thinking! She really needs to rest after the night she had.”
b. “Get the information now, or I’ll report you for not doing your job.”
c. “Never mind – I will do it myself.”
d. “ We need her weight daily, at the same time.”

A

d. “ We need her weight daily, at the same time.”

30
Q

Peripheral catheters are used for

A

short-term use (e.g., fluid restoration after surgery and short-term antibiotic administration). (regular IV fluids)

31
Q

central catheters and implanted ports are used for

A

long term use. These empty into a central vein.

  • used for very concentrated fluids (chemo drugs, total parental nutrition) otherwise it will destroy the line
  • It is a long line bc it gets threaded all the way to the heart
    (e. g. PICC lines, triple lumen central catheters)
32
Q

another name for Electronic infusion devices (EIDs)

A

IV pump

33
Q

EID (IV PUMPS) use _____ pressure to deliver a measured amt of fluid during a specified unit of time

A

POSITIVE

34
Q

Potential complications of IV therapy

A

Circulatory Overload

Infiltration or Extravasation (more serious. cool to touch, with or without PAIN)

Phlebitis

Local/Systemic Infections

Bleeding at Venipuncture Site

35
Q

Infiltration occurs when an IV catheter…

A

becomes dislodged or a vein ruptures and IV fluids inadvertently enter subcutaneous tissue around IV site

36
Q

Extravasation

A

similar to infiltration but this is more serious. Happens when the IV fluid contains additives that damage tissue.

37
Q

S/S of infiltration or extravasation

A

coolness, paleness, and swelling of the area.

When infiltration occurs, immediately assess for any additives in the infiltrated fluid to determine what type of action is needed to prevent local tissue damage and sloughing

38
Q

How often (in general) do peripheral IV lines need to be changed?

A

every 3-4 days, otherwise there is risk of phlebitis

39
Q

phlebitis

A

inflammation of a vein. results from chemical, mechanical, or bacterial causes.

40
Q

Risk factors for phlebitis

A

acidic or hypertonic IV solutions;
rapid IV rate;
IV drugs such as KCL, vancomycin, and penicillin;
VAD inserted in area of flexion

41
Q

CLABSI stands for

A

central line associated blood stream infection

42
Q

clinical manifestations of aspiration

A

• Sudden appearance of respiratory symptoms (such as severe coughing and cyanosis) associated with eating, drinking, or regurgitation
of gastric contents.
• A voice change (such as hoarseness or a gurgling noise) after swallowing.
• Small-volume aspirations that produce no overt symptoms are common and are often not discovered until the condition progresses
to aspiration pneumonia.

43
Q

Aspiration pneumonia

A

• Older persons with pneumonia often complain of significantly fewer symptoms than their younger counterparts; for this reason,
aspiration pneumonia is under-diagnosed in this group.
• Delirium may be the only manifestation of pneumonia in elderly persons.
• An elevated respiratory rate is often an early clue to pneumonia in older adults; other symptoms to observe for include fever, chills,
pleuritic chest pain and crackles.
• Observation for aspiration pneumonia should be ongoing in high-risk persons

44
Q

Why is the Syringe test “whoosh test” NOT the best indicator for NGT placement?

A

Bc you can also hear the whooshing sound in the lungs!

45
Q

What is the gold standard for checking NG tube placement?

A

x-ray

46
Q

using pH color charts to check gastric contents

A

gastric contents should have pH of 0-4

most accurate would be to take it after PT has been fasting for a few hours

47
Q

percutaneous endoscopic gastrostomy (PEG)

A
  • G tube placement via percutaneous endoscopy (usually an outpatient procedure)
  • Using endoscopy, a gastrostomy tube is inserted through esophagus into stomach and then pulled through a stab wound made in abdominal wall
48
Q

PEG versus G tube surgery

A
  • PEGs are less expensive, less invasive, and less time consuming compared to open G tube surgery)
  • in open G tube surgery you need general anesthesia
49
Q

What types of electrolyte imbalances might you see with tube feeding?

A

glucose (might become hyper- or hypo-glycemic)

-also HYPOkalemic

50
Q

Can a PT with dysphagia lay down immediately after a feeding

A

NO! Stay elevated for at least 30 minutes

51
Q

who prepares parenteral nutrition (PN)?

A

pharmacist or a trained tech under strict aseptic techniques

52
Q

How long (approx) are parenteral nutrition solutions good for?

A

24 hours (refrigerate 30 min before use)

53
Q

Total parenteral nutrition (TPN) vs. peripheral parenteral nutrition (PPN)

A

TPN: can be used long term (central line is used
PPN: not used long term, peripheral vein used, pre-prepared solution (good for 24 hours)

54
Q

Potential complications of PN

A

◦ Infection – CLABSI (cental line associated bloodstream infection)
◦ Metabolic problems (risk of hypokalemia)
◦ Mechanical problems (infiltration, traveling embolus)
◦ Insertion problems
◦ Dislodgement, thrombosis of great vein, phlebitis

FINAL exam - A&E CK (7 decks)

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