MED SURG: CHAPTER 17 FLUID, ELECTROLYTE, AND ACID-BASE IMBALANCES

MED SURG: CHAPTER 17 FLUID, ELECTROLYTE, AND ACID-BASE IMBALANCES The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum. - Answer A A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours - Answer C A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Presence of edema d. Hourly urine output - Answer B The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. "Increase fluids if your mouth feels dry. b. "More fluids are needed if you feel thirsty." c. "Drink more fluids in the late evening hours." d. "If you feel lethargic or confused, you need more to drink." - Answer A A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel. - Answer D Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast." - Answer D A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a. Assign the patient to a room near the nurse's station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place an order for a low-salt diet. - Answer A IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion. - Answer B A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L. - Answer A A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis - Answer D The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided imagery. - Answer C An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema c. Confusion d. Restlessness - Answer B A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema - Answer A Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg - Answer C Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis - Answer A The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every evening - Answer A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseau's and Chvostek's signs. d. Encourage fluid intake up to 4000 mL every day. - Answer D To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast - Answer B Foods high in phosphate include milk and other dairy products, so these are restricted on lowphosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted. A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives - Answer A Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a. "There is a decreased risk for infection when 25% dextrose is infused through a central line." b. "The prescribed infusion can be given much more rapidly when the patient has a central line." c. "The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line." d. "The required blood glucose monitoring is more accurate when samples are obtained from a central line." - Answer C The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Position the patient's face toward the CVAD during injection cap changes. - Answer B The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. The patient should turn away from the CVAD during cap changes. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L) - Answer C The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1° F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Gradually decreasing level of consciousness (LOC) d. Weight gain of 2 pounds (1 kg) above the admission weight - Answer C The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill - Answer C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema