Unit 4: Ch. 39 Fluid & Electrolyte Balance Flashcards
A nurse caring for a hospitalized patient with dehydration is told in the shift report that the patient’s laboratory results have just come in. The nurse recognizes which abnormal lab values that can reflect a fluid volume deficit? (Select all that apply.)
a. Sodium (Na) level 150 mEq/L
b. Potassium (K) level 3.5 mEq/L
c. Calcium (Ca) level 9.5 mg/dL
d. Blood urea nitrogen (BUN) 27 mg/dL
Answer: a, d
The sodium and BUN levels are elevated, which can often be seen in dehydrated clients. Normal sodium levels for adults range from 135 to 145 mEq/L. Normal BUN levels for adults range from 10 to 20 mg/dL. The potassium and calcium values are within normal limits.
A patient has reported a 2-kg (4.4-lb) weight gain over the past 3 days. Which assessment cues should the nurse recognize as additional evidence for a nursing diagnosis of Fluid Volume Overload (Hypervolemia)? (Select all that apply.)
a. Third spacing/edema
b. Potassium intake
c. Bounding, rapid pulse
d. Crackles in lungs
e. Dry mucous membranes
Answer: a, c, d
An increased hydrostatic pressure or a decreased oncotic capillary pressure can cause fluid to move to the periphery, causing edema or third spacing. This can cause weight gain, as fluid is not removed by the kidneys from the bloodstream. Patients with fluid overload may have a rapid, bounding pulse and/or crackles in the lungs. Potassium intake and dry mucous membranes is not a sign of fluid retention.
For a patient with a nursing diagnosis of Dehydration, the nurse recognizes which cues as signs and symptoms of dehydration? (Select all that apply).
a. Hypertension
b. Elevated urine specific gravity
c. Dry mucous membranes
d. Weak, thready pulse
e. Pale yellow urine
Answer: b, c, d
Depending on the severity of fluid volume deficit, the patient may have hypotension. Hypertension occurs with fluid volume overload. With dehydration, the urine becomes concentrated with an elevated specific gravity and usually turns dark amber colored (not pale yellow). The skin is usually flushed and dry, and the pulse is weak and thready.
The nurse is caring for a patient with hypocalcemia who does not like milk. Which food should the nurse encourage the patient to consume?
a. Cod
b. Eggs
c. Spinach
d. Tomatoes
Answer: c
Dark leafy vegetables such as spinach, kale, turnip greens, broccoli, Brussels sprouts, and cabbage are sources high in calcium.
A nurse in the emergency department is caring for an adult patient with traumatic abdominal injuries. The patient’s pulse rate has increased from 90 to 120 beats/min over the past hour and the patient is experiencing orthostatic hypotension. For which imbalance should the nurse assess?
a. Respiratory acidosis
b. Extracellular fluid volume deficit
c. Metabolic alkalosis
d. Intracellular fluid volume excess
Answer: b
The elevated heart rate and orthostatic hypotension show extracellular fluid volume deficit. With the client’s injuries, there is the potential for internal bleeding. As circulating blood volume decreases, the heart rate increases to maintain normal cardiac output, and the patient may experience orthostatic hypotension and lightheadedness with position changes. Respiratory acidosis and metabolic alkalosis do not have as a symptom a rapidly increasing pulse rate. Intracellular fluid volume excess causes pulmonary congestion and cerebral edema.
The nurse is assessing the intravenous (IV) site in the right antecubital and notices that the area about 1 inch around it is cool, swollen, firm, and tender to touch. Which action should the nurse take first?
a. Take patient’s temperature.
b. Apply an ice pack to site.
c. Stop infusion and remove IV catheter.
d. Call the primary care provider immediately.
Answer: c
The area around an IV infiltration is cool, swollen, firm, and tender to touch. The first intervention to take for an infiltrated IV is to stop the infusion and discontinue the IV/remove the catheter. Applying cold compresses may be appropriate for hyperosmolar fluids but only after the IV infusion has been stopped. Taking the temperature would be an assessment to make if the complication of infection is suspected. The primary care provider does not need to be notified unless grade 3 or 4 infiltrations are noted (> 6 inches edema).
Which activity is important to include in the plan of care for a patient with a peripherally inserted central catheter (PICC)? (Select all that apply.)
a. Change the PICC dressing only when it becomes soiled or loose.
b. Change the IV tubing every 5 to 7 days.
c. Take blood pressure in the arm without the PICC line.
d. Use only macro drip tubing with IV infusions through the PICC line.
e. Use alcohol-impregnated disinfection caps on needleless ports when not in use.
Answer: c, e
PICC dressings should be changed every 5 to 7 days regularly using sterile technique for transparent dressings and gauze dressings must be changed every 48 hours. This is to keep the site sterile and prevent central line associated blood stream infections (CLABSIs). Dressings should also be changed whenever wet, soiled, or loose. PICC IV tubing is usually changed every 24 hours depending on facility policy. Never take blood pressure in an arm with a PICC. Macro drip or microdrip tubing can be used for infusions through a PICC. Green or orange disinfection caps are alcohol impregnated and should be used to keep ports clean when not in use.
The nurse has just begun an infusion of packed red blood cells (PRBCs). Which of the following cues should the nurse recognize as indicating a transfusion reaction that warrants stopping the infusion? (Select all that apply.)
a. Patient complains of weakness and fatigue.
b. Patient complains of feeling itchy.
c. Patient is shivering and complains of chills.
d. Temperature increased from 99.1° degrees to 101.3° F.
e. Patient complains of nausea.
Answer: b, c, d
Weakness and fatigue are commonly experienced in anemic patients needing a blood transfusion. Itching or hives can be a sign of an allergic reaction. Shivering/chills can indicate hemolytic or nonhemolytic reactions as well as infection due to bacterial contamination. An increased temperature of more than 2 degrees Fahrenheit indicates a reaction; the infusion should be stopped and primary care provider and blood bank notified. Nausea is not a side of effect of a transfusion reaction.
Place the following steps in the correct sequence for starting a peripheral intravenous infusion.
a. Insert needle until there is blood return.
b. Cleanse the site using chlorhexidine and allow to air-dry.
c. Apply tourniquet for maximum of 1 minute while palpating veins and then release.
d. Release tourniquet.
e. Stabilize, connect, and flush with normal saline.
f. Gather all equipment and perform hand hygiene.
g. Dispose of needle in sharps container and document.
h. Use securement device or sterile dressing with label.
i. Reapply tourniquet using a quick-release knot.
Answer: f, c, i, b, a, d, e, h, g
See Skill 39.1. First, gather appropriate equipment and perform hand hygiene. Explain the procedure to the patient and ensure privacy. Set up equipment—tear tape, layout supplies, prime the IV saline lock with normal saline. Select an appropriate site and vein and apply the tourniquet while palpating. Release the tourniquet and reapply with a quick-release knot when ready to start IV. Cleanse the skin with chlorhexidine, and do not touch the site again. Insert the needle at the correct angle while stabilizing the skin. Insert the needle until you see blood return. Release the tourniquet. Stabilize the catheter, remove the needle, and connect it to the saline lock. Then, flush with normal saline. Use a securement device or sterile dressing with a label per facility protocol. Put the needle in the sharps container and clean up supplies. Lower the bed and ensure patient safety, perform hand hygiene after disposal of gloves, and document the procedure in the medical record.
Decreased serum calcium level
Hypocalcemia
Increased intravascular volume but does not cause fluid shifts in or out of the cell
Isotonic solution
An abnormal collection of fluid within the peritoneal cavity
Ascities
Decreased serum sodium levels
Hyponatremia
Fluid overload
Hypervolemia
Decreased oxygen concentration of arterial blood
Hypoxemia
