LACHARITY 4 Fluid, Electrolyte, and Acid-Base Balance Problems Flashcards
The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day.
What is the RN’s priority concern?
1. Ask the client about his or her bowel movements.
2. Have the client complete a diet diary for the past 2 days.
3. Instruct the client to increase oral intake to 2 to 3 L/day.
4. Ask the client to describe his urine output.
Ans: 3 An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the RN would want to know about bowel movements, dietary intake, and urine output, in this case, the priority is that the client is
not taking in enough oral fluids. Focus: Prioritization.
The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)?
- Administering IV fluids as prescribed by the physician
- Providing straws and offering fluids between meals
- Developing a plan for added fluid intake over 24 hours
- Teaching family members to assist the client with fluid intake
Ans: 2 UAPs can reinforce additional fluid intake when it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN.
Focus: Delegation, Supervision;
Test Taking Tip: The nurse must be familiar with the scope of practice for UAPs before delegating client care
tasks. UAP scope of practice includes checking vital signs, tasks associated with activities of daily living such as bathing and oral care, feeding, and recording intake and output. UAPs can provide items such as drinking
straws and can encourage and remind clients about instructions from the nurse such as increasing fluid intake.
The unlicensed assistive personnel (UAP) reports to the nurse that a client’s urine output for the past 24 hours has been only 360 mL. What is the nurse’s priority action at this time?
- Place an 18-gauge IV in the nondominant arm.
- Elevate the client’s head of bed at least 45 degrees.
- Instruct the UAP to provide the client with a pitcher of ice water.
- Contact and notify the health care provider immediately.
Ans: 4 The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The client may need additional fluids (IV or oral) after the cause of the low urine output is determined. Elevating the head of the bed will not help with urine output. Notifying the health care provider is the first priority in this case.
Focus: Prioritization.
The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk?
- Flattened neck veins when the client is in the supine position
- Full and bounding pedal and post-tibial pulses
- Pitting edema located in the feet, ankles, and calves
- Shallow respirations with crackles on auscultation
Ans: 1 Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of excess fluid volume. Focus: Prioritization.
The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply.
- Reminding the client to avoid commercial mouthwashes
- Encouraging mouth rinsing with warm saline
- Assess skin turgor by pinching the skin over the back of the hand
- Observing the lips, tongue, and mucous membranes
- Providing mouth care every 2 hours while the client is awake
- Seeking a dietary consult to increase fluids on meal trays
Ans: 1, 2, 4, 5 The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client shouldbe reminded to avoid most commercial mouthwashes, which contain agents such as alcohol. To assess skin turgor in an older adult, skin tenting is best
checked by pinching the skin over the sternum or on the forehead rather than the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary consult is within the purview of the RN or health care provider.
Focus: Supervision.
The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client’s morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- Weigh the client every morning.
- Maintain accurate intake and output records.
- Restrict fluids to 1500 mL/day.
- Administer furosemide 40 mg IV push.
Ans: 4 Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but are not
urgent.
Focus: Prioritization.
Which statement by a client with hypovolemia related to dehydration is the best indicator to the nurse of the need for additional teaching?
- “I will drink 2 to 3 L of fluids every day.”
- “I will drink a glass of water whenever I feel thirsty.”
- “I will drink coffee and cola drinks throughout the day.”
- “I will avoid drinks containing alcohol.”
ANS: 3 Mild dehydration is very common among healthy adults and is corrected or prevented easily by matching fluid intake with fluid output. Teach all adults to drink more fluids, especially water. Beverages with caffeine can increase fluid loss, as can drinks containing alcohol. These beverages should not be used to prevent or treat dehydration.
Focus: Prioritization
The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse that the client has developed prominent U waves. Which laboratory value should be checked immediately?
- Sodium
- Potassium
- Magnesium
- Calcium
Ans: 2 Suspect hypokalemia and check the client’s potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with ypokalemia may also develop heart block. Other abnormal electrolyte levels can affect cardiac rhythms, but the occurrence of U waves is associated with low potassium levels.
Focus: Prioritization.
A client’s potassium level is 6.7 mEq/L (6.7 mmol/L). Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising?
- Administer sodium polystyrene sulfonate 15 g orally.
- Administer spironolactone 25 mg orally.
- Assess the electrocardiogram (ECG) strip for tall T waves.
- Administer potassium 10 mEq (10 mmol/L) orally.
Ans: 1 The client’s potassium level is high (normal range is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L). Sodium polystyrene sulfonate removes potassium from the
body through the gastrointestinal system. pironolactone is a potassium-sparing diuretic that may cause the client’s potassium level to go even higher. A KCl supplement can also raise the potassium level even higher. The beginning nursing student does not have the skill to assess ECG strips.
Focus: Delegation, Supervision.
A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would the nurse be sure to monitor?
- Hypokalemia
- Hyperkalemia
- Hyponatremia
- Hypernatremia
Ans: 3 SIADH results in a relative sodium deficit caused by excessive retention of water. Focus: Prioritization.
The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate
RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
1. Providing oral care every 3 to 4 hours
2. Monitoring for indications of dehydration
3. Administering 0.45% saline by IV line
4. Record urine output when client voids
5. Assessing daily weights for trends
6. Help the client change position every 2 hours
Ans: 1, 4, 6 Providing oral care, assisting clients to reposition, and recording urine output are within the scope of practice of the UAP. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skills of the RN.
Focus: Assignment, Delegation, Supervision.
An experienced LPN/LVN reports to the RN that a client’s blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time?
- Reassess the client’s blood pressure and heart rate.
- Review the client’s morning calcium level.
- Request a neurologic consult today.
- Check the client’s pupillary reaction to light.
Ans: 2 A positive Chvostek sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The heart rate may be slower or slightly faster than normal, with a weak, thready pulse. Severe hypocalcemia causes severe hypotension. The LPN/LVN is experienced and
possesses the skills to accurately measure vital signs. Focus: Prioritization.
The nurse is preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL [2.25 to 2.63 mmol/L]). Which statement by the client indicates the need for additional teaching?
- “I will call my doctor if I experience muscle twitching or seizures.”
- “I will make sure to take my vitamin D with my calcium each day.”
- “I will take my calcium citrate pill every morning before breakfast.”
- “I will avoid dairy products, broccoli, and spinach when I eat.”
Ans: 4 Clients with low calcium levels should be encouraged to eat dairy products, seafood, nuts, broccoli, and spinach, which are all good sources of
dietary calcium. The other three options indicate correct understanding of calcium therapy.
Focus: Prioritization.
Which order prescribed for a client with hypercalcemia would the nurse be sure to question?
- 0.9% saline at 50 mL/hr IV
- Furosemide 20 mg orally each morning
- Apply cardiac telemetry monitoring
- Hydrochlorothiazide (HCTZ) 25 mg orally each morning
Ans: 4 Calcium excretion is decreased with thiazide diuretics (e.g., HCTZ), so the calcium level is at risk for going even higher. Loop diuretics (e.g., furosemide) increase calcium excretion. The addition of IV fluids and cardiac monitoring are appropriate actions for monitoring and treating a client with hypercalcemia. Focus: Prioritization.
The unlicensed assistive personnel (UAP) asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is the RN’s best response?
- “The client’s low phosphorus is probably due to malnutrition.”
- “The client is just worn out from not getting enough rest.”
- “The client’s skeletal muscles are weak because of the low phosphorus.”
- “The client will do more for himself when his phosphorus level is normal.”
Ans: 3 A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown
(rhabdomyolysis). Phosphate is necessary for energy production in the form of adenosine triphosphate, and when not produced, leads to generalized muscle weakness. Although the other statements are true, they do not answer the UAP’s question.
Focus: Delegation, Supervision.
The RN is reviewing the client’s morning laboratory results. Which of these results is of most concern?
- Serum potassium level of 5.2 mEq/L (5.2 mmol/L)
- Serum sodium level of 134 mEq/L (134 mmol/L)
- Serum calcium level of 10.6 mg/dL (2.65 mmol/L)
- Serum magnesium level of 0.8 mEq/L (0.4 mmol/L)
Ans: 4 Although all of these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias. Focus: Prioritization.
Which client would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day?
1. A 68-year-old client on a ventilator with acute respiratory failure and respiratory acidosis
2. A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent
3. A newly admitted 56-year-old client with diabetic ketoacidosis receiving aninsulin drip
4. A 38-year-old client on a ventilator with narcotic overdose and respiratory
alkalosis
Ans: 2 The client with COPD, although ventilator dependent, is in the most stable condition of the clients in this group and should be assigned to the float nurse from the step-down unit. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct
their disorders. In addition, the client with diabetic ketoacidosis is a new admission and require an in-depth admission assessment. All three of these clients need care from an experienced critical care nurse.
Focus: Assignment
The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this
problem?
1. Increase in ventilator rate from 6 to 10 breaths/min
2. Decrease in ventilator rate from 10 to 6 breaths/min
3. Increase in oxygen concentration from 30% to 40%
4. Decrease in oxygen concentration from 40% to 30%
Ans: 1 The blood gas component responsible for respiratory acidosis is carbon dioxide, thus increasing the ventilator rate will blow off more carbon dioxide and decrease or correct the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.
Focus: Prioritization.
Which actions should the nurse delegate to an unlicensed assistive personnel (UAP) for the client with diabetic ketoacidosis? Select all that apply.
- Checking fingerstick glucose results every hour
- Recording intake and output every hour
- Measuring vital signs every 15 minutes
- Assessing for indicators of fluid imbalance
- Notifying the provider of changes in glucose level
- Assisting the client to reposition every 2 hours
Ans: 1 The blood gas component responsible for respiratory acidosis is carbon dioxide, thus increasing the ventilator rate will blow off more carbon dioxide and decrease or correct the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.
Focus: Prioritization.
The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances?
- History of myocardial infarction (MI) 1 year ago
- Antacid use for occasional indigestion
- Shortness of breath with extreme exertion
- Chronic renal insufficiency
Ans: 4 Risk factors for acid-base imbalances in older adults include chronic kidney disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis. The MI occurred 1 year ago and is no longer a risk factor.
Focus: Prioritization
A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding would the nurse instruct the student to report immediately?
- Respiratory rate of 8 to 10 breaths/min
- Decrease in pain level from 6 to 2 (on a scale of 1 to 10)
- Request by the client that the room door be closed
- Heart rate of 90 to 100 beats/min
Ans: 1 A decreased respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. All of the other findings are important and should be reported to the RN, but the respiratory rate demands urgent attention.
Focus: Delegation, Supervision.
The unlicensed assistive personnel (UAP) reports to the nurse that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should the nurse suspect?
- Respiratory acidosis
- Respiratory alkalosis
- Metabolic acidosis
- Metabolic alkalosis
Ans: 2 The client is most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and cause respiratory alkalosis. Eliminating carbon dioxide would lead to an alkalosis. Metabolic imbalances would be related to renal changes.
Focus: Prioritization, Supervision.
A client is admitted to the oncology unit for Chemotherapy. To prevent an acid-base problem, which finding would the nurse instruct the unlicensed
assistive personnel (UAP) to report?
1. Repeated episodes of nausea and vomiting
2. Reports of pain associated with exertion
3. Failure to eat all the food on the breakfast tray
4. Client hair loss during the morning bath
Ans: 1 Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed but are not related to acid-base imbalances.
Focus: Prioritization, Supervision.
The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client’s respiratory rate and depthhas decreased. What is the nurse’s best response?
- “It’s common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing.”
- “The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism.”
- “Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem.”
- “The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis.”
Ans: 2 Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client’s decrease in rate and depth of ventilation is an attempt to compensate by retaining carbon dioxide. The first response may be true, but it does not address all the components of the question. The third and fourth answers are inaccurate.
Focus: Supervision, Prioritization.
