Unit 4 Practice Flashcards
What substance increases H+ concentration?
Acids
What substance decreases H+ concentration?
Base
Blood is slightly… at pH 7.35 to 7.45
Alkaline
Blood pH less than 7.35 is…
acidosis; caused by too many hydrogen ions or too little bicarbonate
Blood pH greater than 7.45 is…
alkalosis; caused by too little hydrogen ions or too much bicarbonate
Which three mechanisms regulate acid-base balance?
the buffer system, respiratory system, and renal system
The primary regulator of acid-base balance
Buffers
How do buffers neutralize acids?
buffers act chemically to change strong acids to weak acids or bind acids to neutralize them
Which systems are required for the buffer system to function adequately?
- Nervous System
- Hepatic System
- Respiratory System
- Endocrine System
- Renal System
- Muscular System
respiratory and renal systems must be functioning adequately
RATIONALE: Respiration rate determines the level of CO2 in the blood. Increased respirations lead to increased CO2 elimination, decreasing CO2 in blood. Decreased respirations do the reverse leading to CO2 retention. Kidneys conserve bicarbonate and excrete some acid. Cellular metabolism produces acids (carbonic and metabolic); lungs excrete carbonic acids; kidneys excrete metabolic acids.
How do carbonic acid (H2CO3) and bicarbonate (HCO3-) work on each other?
a strong acid + a strong base are broken down into salt and weak acid
How do the kidneys regulate acid-base balance?
the kidneys conserve bicarbonate and excrete some acid
what are the three mechanisms for acid excretion?
secrete free hydrogen, combine H+ with ammonia (NH3), excrete weak acids
What information can be observed through arterial blood gas (ABG) values?
acid-base statues, underlying cause of imbalance, body’s ability to regulate pH, shows the PaO2 (partial pressure of arterial O2) and O2 saturation
R.O.M.E
Respiratory Opposite:
- Alkalosis: ↑ pH ↓ PaCO2
- Acidosis: ↓ pH ↑ PaCO2
Metabolic Equal:
- Alkalosis: ↓ pH ↓ HCO3−
- Acidosis: ↓ pH ↓ HCO3−
Organs involved in bowel elimination
colon, rectum, anus, peristalsis, sphincter, gastrocolic reflex
Organs involved in urinary elimination
bladder, urethra, internal/external sphincter
What are the functions of the kidney? Mnemonic: “A WET BED”
A: Acid-base balance
W: Water balance
E: Electrolyte balance
T: Toxin removal
B: Blood pressure control
E: Erythropoietin
D: vitamin D metabolism
What are the individual risk factors of impaired fluid and electrolyte imbalance?
All individuals are at risk, regardless of age, race, or socioeconomic status
Who has the GREATEST risk of fluid and electrolyte imbalance?
the very young and very old
What are the FOUR greatest physiological risk factors that are associated with fluid and electrolyte imbalance?
Excessive production or intake of metabolic acid
Altered acid buffering due to loss or gain of bicarbonate
Altered acid excretion
Abnormal shift of H+ into cellsW
Why are the very young at risk of fluid and electrolyte imbalance?
immature kidneys, high metabolic rate, large body surface area (means that body & lungs greater in size than their body mass) , and increased respiratory rate, high % of body weight is water
Why are the very old at risk of fluid and electrolyte imbalance?
impaired renal function, decreased thirst, and impaired ability to conserve water
What are the signs and symptoms of fluid overload (edema)?
weight gain of 1kg or more in 24 hours for an adult, distended neck when upright (vascular fluid overload), and dependent edema (interstitial fluid overload).
What are the signs and symptoms of fluid deficiency (dehydration)?
weight loss of 1kg or more in 24 hours for an adult, rapid thready pulse, postural hypotension, and flat neck veins when supine (vascular fluid underload), skin testing (interstitial fluid underload), and decreased level of consciousness caused by osmotic shift of water OUT of brain cells
What are the fluid compartments?
Intracellular fluid (ICF): fluid inside cells
Extracellular fluid (ECF): - fluid outside cells
Interstitial: - fluid between the cells
ECF main components:
Interstitial fluid: -fluid in spaces between cells
Intravascular fluid: - extracellular fluid in the vascular space called PLASMA
Transcellular: - cerebrospinal fluid; fluid in GI and joint spaces; pleural, peritoneal, pericardial, and intraocular fluid
What are the primary prevention methods of fluid and electrolyte imbalance?
Patient teaching, Dietary measures, Fluid
management: adequate intake with vomiting or diarrhea; limiting intake
when prone to edema
What are the secondary prevention methods of fluid and electrolyte imbalance?
Screening for fluid and electrolyte imbalance is NOT routine for the general population. Monitoring serum blood levels may be performed as part of disease management.
Why does a nurse monitor for fluid volume deficit in a patient with prolonged vomiting?
- Fluid movement from the cells into the interstitial space and the blood vessels
- Excretion of large amounts of interstitial fluid with depletion of extracellular fluids
- An overload of extracellular fluid with a significant increase in intracellular fluid volume
- Fluid movement from the vascular system into the cells, causing cellular
swelling and rupture.
What is the purpose of fluid and electrolyte balance?
to regulate the body fluid volume, osmolality, and composition
What is the process of fluid and electrolyte balance?
filtration, diffusion, osmosis (water movement across a semipermeable membrane), and selective excretion
What is hypokalemia?
low serum potassium
What is hyperkalemia?
high serum potassium
What is hyponatremia and hypernatremia?
low serum sodium & high serum sodium
S.A.L.T L.O.S.S. (SSO hyponatremia)
S- seizures & stupor
A- Abdominal cramping
L- Lethargic
T- Tendon reflexes diminished; Trouble concentrating
L- Loss of urine & appetite
O- Orthostatic hypotension; Overactive bowel sounds
S- Shallow respirations
S- Spasms of muscles
No F.R.I.E.D Foods for You (SSO hypernatremia)
F- Fatigue
R- Restless; really agitated
I- Increased reflexes (seizure/coma)
E- Extreme thirst (!!!)
D- Decreased urine output, dry mouth/skin
Which bodily process imbalance would the nurse expect for a patient with:
- Acute illness (vomiting, diarrhea)
- Severe burns
- Serious kidney injury or trauma
- Chronic kidney disease
- Major surgery
- Poor nutritional intake
fluid and electrolyte imbalance
What are the physiological consequences of fluid volume defecit?
fluid volume deficit leads to poor perfusion and oxygen delivery throughout the body; decreased blood volume = hypotension and tachycardia
What are the physiological consequences of fluid volume excess?
increased blood volume and hypertension leading to edema
What is glucose regulation achieved through?
a delicate balance between: nutrient intake, hormonal signaling, and glucose uptake by the cell
What is the scope of glucose regulation?
normal or optimal regulation to impaired regulation throughout the lifespan
What are the normal range of blood glucose levels?
Fasting state: 70-99 mg/dL
2 hours post-prandial state: 100-140 mg/dL
hypo-, eu-, and hyperglycemia
hypoglycemia: low concentration of BG
euglycemia: normal concentration of BG
hyperglycemia: high concentration of BG
What is the range of hyperglycemia?
Fasting state: >100 mg/dL
Post-prandial: BG of >140 mg/dL
Severe: >180 mg/dL
What is the range of hypoglycemia?
Post-prandial: BG of <70 mg/dL
Severe: >50 mg/dL
What are the counter-regulatory hormones? What is their purpose?
Glucagon, cortisol, growth hormone, norepinephrine, and epinephrine (aka the stress hormones)
They are released in response to cellular deficiency of glucose. Suppress insulin release; stimulate hepatic glucose production (from glycogen); elevating BG levels.
What are the signs and symptoms of HYPERglycemia?
3 P’s: Polyphagia, Polyuria, Polydipsia (S/S OF KETOACIDOSIS)
Skin: Hot & DRY - Sugar’s HIGH
dehydration, fruity odor breath, Kussmaul breathing (deep & fast), slow/poor wound healing, fatigue, weight loss, hunger
What are the signs and symptoms of HYPOglycemia?
Skin: Cold & Clammy - need some CANDY
diaphoresis, tremors, headache, fatigue & weakness, confusion, irritability, seizure, coma, hunger
What is the only hormone produced that lowers elevated BG levels after carbohydrate intake?
Insulin
What are the main populations at risk for impaired glucose regulation?
- Pregnant women
- Infants
- Older adults
- American Indian/Alaska Natives
- African Americans
- Hispanic/Latino
- Asian Americans
Why are pregnant women at risk of diabetes? What prevention methods are used for pregnant women?
Hormonal changes (mainly produced by the placenta) cause insulin resistance, leading to hyperglycemia (especially postprandial)
All pregnant women are screened during the 24-28 gestational mark. Women with pre diabetes or known risk factors for T2D are screened at the first prenatal visit.
What makes older people have a higher risk for impaired glucose regulation?
increase in visceral fat; reduction in muscle mass (age-related); reduced insulin production (age-related); and reduced capacity to regulate/metabolize glucose concentration (age-related)
What are the lifestyle risk factors of impaired glucose regulation?
Diet high in saturated fat; excess caloric intake of carbohydrates (leading to obesity); low fiber intake and physical inactivity
What are the PRIMARY prevention methods for impaired glucose regulation?
maintain optimal body weight; regular physical activity; balanced diet
What are the SECONDARY prevention methods for impaired glucose regulation?
Recommendations vary but for adults’ risk factors for diabetes, pregnant women, screening to detect complications, A1C measurements twice a year, annual renal function, dental, foot, and eye examinations
What are the HgbA1C levels expected for patients?
Non-diabetics: less than 5.7
Diabetics: less than 7.0
What should the diabetic patient receive education for promoting SELF-MANAGEMENT?
HINT: Don’t Eat When Mary’s Growing Mushrooms
Diet
Exercise
Weight control
Medication management
Getting adequate rest
Maintain awareness of complication
How is hypoglycemia corrected?
15/15: 15 grams of fast-acting carbohydrate; check BG in 15 minutes
Severe hypoglycemia: 30g of fast acting carb or IV dextrose or glucagon in unconscious patients
Patient may rebound to very high BG after being hypoglycemic
What is insulin replacement?
when a patient requires both basal (or long acting) insulin and mealtime (or short-/fast-acting) insulin to achieve euglycemia
What is the typical ratio of insulin?
T1D: 1 unit per every 15g of carbs (1 serving)
Active adults or children: 1 unit for every 30g of carbs
Obese, insulin resistant: 1 unit for every 2-3G of carbs
What is stress incontinence?
increased abdominal pressure –> increased bladder pressure stronger than the external urethral sphincter; more common in women (typically due to pregnancy, vaginal delivery, and shorter urethra); leakage of urine in small amounts from physical pressure (coughing, sneezing, exercising)
What is urge incontinence?
sometimes called “over-active bladder”; urge -> pee at unexpected times; detrusor muscle is over-active/dysfunctional causing unexpected spasms (including during sleep)
What is functional incontinence?
cognitive, physical disability (arthritis, mobility barriers), or external obstacles that prevent person from reaching toilet
What is mixed incontinence?
a mixture of stress and urge incontinence
What is overflow incontinence?
“under-active bladder”; weaker detrusor muscle or decrease in urethral space or blockage (e.g., enlarged prostate compressing urethra); unexpected leakage of small amount; weak stream; delayed stream
What is transient incontinence?
leakage that occurs temporarily because of a situation that will pass (infection, new medication, colds with coughing)
What is the color of NORMAL urine?
transparent (over- hydration), pale yellow (healthy and hydrated), transparent yellow, dark yellow (normal but needs to drink more water)
What is the color of ABNORMAL urine?
brownish orange (dehydration or liver disease), pinkish-red (kidney disease, UTI, or tumor), blue or green (rare genetic disease), foamy (kidney disease)
Constipation is a side effect of which supplement?
Iron
As the uterus enlarges during pregnancy, the pressure it puts on veins can cause what problem with elimination?
It can cause the veins to swell, leading to hemorrhoids
A diet lacking in fiber contributes to…
constipation
During the third trimester, the growing baby causes the uterus to rise out of the pelvic cavity, displacing organs which results in…
pressure on the colon that decreases gastric motility
How does inadequate water consumption impact bowel elimination?
causes stools to become dry and difficult to pass
Elimination is related to which nursing concepts?
- Hormonal regulation
- Nutrition
- Inflammation
- Cellular regulation
- Fluid and electrolytes
- Mobility
- Sexuality
- Acid-base balance
nutrition, cognition, mobility, fluid and electrolytes, and acid-base balance
What are the primary prevention strategies for impaired bowel and urinary incontinence?
hydration (helps stool pass easier; reduces bladder irritation), adequate fiber intake (helps stool pass easier), regular toileting (prevents UTI), regular exercise (promotes peristalsis), avoidance of environmental contamination (prevents diarrhea or parasites from unclean food/water)
What are the secondary prevention strategies for impaired bowel and urinary incontinence?
colonoscopy & occult blood screening (detect colon cancer) beginning at age 50-75 years of age; and prostate cancer screening for men 55-69 years old
What should be taken into consideration for the elimination habits of young children?
- infants and toddlers lack control over voluntary sphincter muscles
- children begin to identify the urge to void/defecate at 18-24 months
- toilet training helps the child gain conscious control of their elimination and can usually begin between 2-3 years of age
What is retention? Is it intentional or unintentional?
it is the UNINTENTIONAL retention of urine or stool and can occur at any age; it leads to incomplete bladder emptying or anuria; or it leads to inability to pass stool that leads to constipation or fecal impaction
What is diffusion?
movement from high to low concentration (does not require external energy)
What is facilitated diffusion?
bigger molecules use helper proteins in the phospholipid membrane to move across the cell membrane from high to low concentration (no energy)
What is active transport?
molecules move against the concentration gradient (low to high) through the use of ATP
What is osmosis?
water moves through a semipermeable membrane (used only for water) from high to low concentration (no energy)
What are the ranges for blood pH?
Acidotic: <7.35
Normal: 7.35-7.45
Alkalotic: >7.45
What are the ranges for HCO3?
Acidotic: <22
Normal: 22-26
Alkalotic: >26
What are the ranges for PaCO2?
Acidotic: >45
Normal: 35-45
Alkalotic: <35
The patient has a pH of 7.23, PaCO2 of 50, and HCO3 of 30. Identify their problem.
Respiratory acidosis partially compensated
RATIONALE: pH and PaCO2 are acidotic; PaCO2 indicates respiratory problem; HCO3 is alkalotic, indicating compensation
The patient has a pH of 7.53, PaCO2 of 23, and HCO3 of 18. Identify their problem.
Respiratory alkalosis partially compensated
RATIONALE: pH and PaCO2 are alkalotic; PaCO2 indicates respiratory; HCO3 is acidotic, indicating compensation.
The patient has a pH of 7.20, PaCO2 of 38, and HCO3 of 17. Identify their problem.
Metabolic acidosis uncompensated
RATIONALE: pH and HCO3 are acidotic; HCO3 indicates metabolic; PaCO2 is within normal range, indicating no compensation
The patient has a pH of 7.48, PaCO2 of 42, and HCO3 of 35. Identify their problem.
Metabolic acidosis uncompensated
RATIONALE: pH and HCO3 are alkalotic; HCO3 indicates metabolic; PaCO2 is within normal range, indicating no compensation.
The patient has a pH of 7.21, PaCO2 of 50, and HCO3 of 28. Identify their problem.
Respiratory acidosis partially compensated
RATIONALE: pH and PaCO2 are acidotic; PaCO2 indicates respiratory; HCO3 is alkalotic, indicating compensation
The patient has a pH of 7.50, PaCO2 of 47, and HCO3 of 27. Identify their problem.
Metabolic alkalosis partially compensated
RATIONALE: pH and HCO3 are alkalotic; HCO3 indicates metabolic; PaCO2 is acidotic, indicating compensation
The patient has a pH of 7.42, PaCO2 of 26, and HCO3 of 18. Identify their problem.
Respiratory alkalosis fully compensated
RATIONALE: pH is on the alkalotic range of ‘normal’ (above 7.40); PaCO2 is also alkalotic, indicating a respiratory problem; HCO3 is acidotic indicating compensation, BUT since the pH is within normal range it is FULLY compensated.
The patient has a pH of 7.37, PaCO2 of 32, and HCO3 of 17. Identify their problem.
Metabolic acidosis fully compensated
RATIONALE: pH is in the acidotic range of ‘normal’ (below 7.40); HCO3 is ALSO acidotic, indicating a metabolic problem; PaCO2 is alkalotic indicating compensation, BUT since the pH is within normal range it is FULLY compensated.
Which are indicators of nutritional risk in a pregnant client who is of normal weight?
- Fasting blood sugar of 80 mg/dL
- Smoker
- Hemoglobin of 12 g/dL
- Term delivery 2 years ago
- Twin gestation
Smoker and twin gestation
RATIONALE: Smokers generally have a nutrient-poor diet and are at risk for continuing the same diet throughout pregnancy. Multifetal pregnancies require nutrition above the normal requirements for pregnancy. Term delivery 2 years ago does not put the client at risk as it would if the pregnancies were a year or less apart.
Which client would the nurse care for first based on vital signs?
Client 1: Respirations 14 bpm; BP: 140/86 mm Hg
Client 2: Respirations 20 bpm; SpO2: 90%
Client 3: Respirations: 28 bpm; SpO2: 70%
Client 4: Respirations: 16 bpm; BP: 128/62 mmHg
Client 2
RATIONALE: Respiratory rate is high and SpO2 is very low, requiring immediate treatment.
The nurse is caring for a client who has a poor understanding of weight-reduction strategies. The nurse instructs the client to follow a healthy diet regularly because crash dieting can lead to serious health issues. Which of these reactions might the nurse expect if the client is in the pre-contemplation stage?
- “I’m trying really hard to stick to the diet chart, but sometimes I skip lunch.”
- “All I know is that having a thin body means that I’m healthy.”
- “Can you tell me how to lose weight by eating a normal diet?”
- “Who said that I don’t eat properly? I just skip breakfast.”
5.”Following the diet plan isn’t important to me; I just care about losing weight as fast as possible.”
2, 4, and 5.
Rationale: In the pre contemplation stage, the client does not intend to make changes in the next six moths and may become defensive when confronted with information on the benefits of changing habits.
The client stating that they want to learn indicates preparation stage. The client trying to abide by the chart but sometimes skipping meals is indicative of the action stage.
A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How would the nurse evaluate for bladder distension?
- Catheterizing
- Palpating
- Asking the client about their urgency
- Assessing pain
By palpating the client’s suprapubic area gently.
RATIONALE: Palpation will indicate bladder distention. Patient may not experience discomfort due to increased intra-abdominal space. Assessment should be performed prior to intervention. Trauma to the region may result in the patient not experiencing urgency despite a full bladder.
Hypoglycemic agents are used for which type of diabetes? Why?
Hypoglycemic patients are used for Type 2 diabetes only. Type 1 diabetes is unresponsive to stimulation with oral hypoglycemic agents.
What consequences can you expect in patients with hypoglycemia?
neurological changes, seizures, cognitive impairment, gastroparesis
What consequences can you expect in patients with hyperglycemia?
antipathy, peripheral neuropathy, fluid, electrolyte, and acid-base imbalance
What will be the collaborative efforts for a patient with impaired glucose regulation?
patient education, self checking, nutrition, and pharmacological interventions
What is an anion with a normal serum electrolyte value of 22-26 mEq/L (22-26 mmol/L)?
Bicarbonate
What is an anion with a normal serum electrolyte value of 98-106 mEq/L (98-106 mmol/L)?
Chloride (Cl-)
What is an anion with a normal serum electrolyte value of 22-26 mEq/L (22-26 mmol/L)?
Bicarbonate
What is an anion with a normal serum electrolyte value of 98-106 mEq/L (98-106 mmol/L)?
Chloride (Cl-)
What is an anion with a normal serum electrolyte value of 3.0-4.5 mg/dL (0.97-1.45 mmol/L)?
Phosphate
What is an cation with a normal serum electrolyte value of 9.0-10.5 mg/dL (2.25-2.62 mmol/L)?
Calcium (Ca2+)
What is an cation with a normal serum electrolyte value of 1.3-2.1 mg/dL (0.65-1.05 mmol/L)?
Magnesium (Mg2+)
What is an cation with a normal serum electrolyte value of 3.5-5.0 mEq/L (3.5-5.0 mmol/L)?
Potassium (K+)
What is an cation with a normal serum electrolyte value of 136-145 mEq/L (136-145 mmol/L)?
Sodium (Na+)
What is the normal serum electrolyte value for bicarbonate? Is it an anion or cation?
22-26 mEq/L (22-26 mmol/L); bicarbonate is an anion
What is the normal serum electrolyte value for Chloride (Cl)? Is it an anion or cation?
98-106 mEq/L (98-106 mmol/L); Chloride (Cl-) is an anion
What is the normal serum electrolyte value for Phosphate? Is it an anion or cation?
3.0-4.5 mg/dL (0.97-1.45 mmol/L); Phosphate is an anion
What is the normal serum electrolyte value for Calcium (Ca)? Is it an anion or cation?
9.0-10.5 mg/dL (2.25-2.62 mmol/L); Calcium (Ca2+) is a cation
What is the normal serum electrolyte value for Magnesium? Is it an anion or cation?
1.3-2.1 mg/dL (0.65-1.05 mmol/L); Magnesium (Mg2+) is a cation
What is the normal serum electrolyte value for Potassium? Is it an anion or cation?
3.5-5.0 mEq/L (3.5-5.0 mmol/L); Potassium (K+) is a cation
What is the normal serum electrolyte value for Sodium? Is it an anion or cation?
136-145 mEq/L (136-145 mmol/L); Sodium (Na+) is a cation
What is a nursing diagnosis for Heat Exhaustion: Severe Dehydration?
What is a nursing diagnosis for Pulmonary & Peripheral Edema: CHF?
Fluid volume excess evidenced by CHF related to pulmonary edema (pitting)
What is a nursing diagnosis for Hypokalemia: Loop Diuretic Use?
What is a nursing diagnosis for Hyponatremia: High Sodium Diet/Inadequate Fluid Intake?
