Hinkle Chapter 13: Fluid and Electrolytes:
Balance and Disturbance
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia:
pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these
values indicate? -
respiratory alkalosis
A client with pneumonia may hyperventilate in an effort to increase oxygen intake.
Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis —
indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys'
bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The
below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2
loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance
has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.
Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone
(SIADH) secretion is experiencing complications? -
jugular vein distension
SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention.
Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular
vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight
gain and fluid retention (secondary to oliguria).
Which findings indicate that a client has developed water intoxication secondary to treatment
for diabetes insipidus? -
confusion and seizures
Classic signs of water intoxication include confusion and seizures, both of which are caused
by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN
levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water
intoxication.
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:
-
muscle weakness
Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue,
and face are findings associated with hyperkalemia, which is transient and results from
transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and
constipation aren't seen in hyperkalemia.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should
the nurse assess first? -
pulse
1|Page
,An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which
the nurse can detect immediately by palpating the pulse. In addition to assessing the client's
pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur
suddenly. The client's blood pressure may change, but only as a result of the arrhythmia.
Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing
respirations and temperature because these aren't affected by the serum potassium level.
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of
solution? -
acidic
Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is
considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
Which electrolyte is a major anion in body fluid? -
chloride
Chloride is a major anion found in extracellular fluid. Potassium, sodium, and calcium are
cations.
Which could be a potential cause of respiratory acidosis? -
hypoventilation
Respiratory acidosis is always due to inadequate excretion of CO2, with inadequate
ventilation, resulting in elevated plasma CO concentration, which causes increased levels of
carbonic acid. In addition to an elevated PaCO2, hypoventilation usually causes a decrease in
PaO2.
A client's potassium level is elevated. The nurse is reviewing the ECG tracing. Identify the
area on the tracing where the nurse would expect to see peaks. -
Peaked narrow T wave
Potassium influences cardiac muscle activity. Alterations in potassium levels change
myocardial irritability and rhythm. Hyperkalemia is very dangerous; cardiac arrest can occur.
Cardiac effects of elevated serum potassium are significant when the level is above 8 mEq/L.
Hyperkalemia causes skeletal muscle weakness and even paralysis, related to a depolarization
block in t muscle. Therefore, ventricular conduction is slowed. The earliest change that can
be seen are peaked, narrow T waves on the ECG.
Which of the following is a factor affecting an increase in urine osmolality? -
syndrome of inappropriate anti diuretic hormone release
Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and
congestive heart failure. Myocardial infarction typically is not a factor that increases urine
osmolality.
A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking
ethacrynic acid (Edecrin) for hypertension. Based on these symptoms, the client will be
evaluated for which electrolyte imbalance? -
hypokalemia
2|Page
, Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias,
leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid
(Edecrin), also waste potassium.
Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and
cardiac dysrhythmias.
Signs of hypocalcemia include tingling in the extremities and the area around the mouth and
muscle and abdominal cramps.
Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria,
thirst, pathologic fractures, and mental changes.
The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic
alkalosis. Which nursing actions are required to manage this client? Select all that apply. -
Compare ABG findings with previous results.
Maintain intake and output records.
Document presenting signs and symptoms.
Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate
or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and
increased base bicarbonate. Nursing management includes documenting all presenting signs
and symptoms to provide accurate baseline data, monitoring laboratory values, comparing
ABG findings with previous results (if any), maintaining accurate intake and output records
to monitor fluid status, and implementing prescribed medical therapy.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is
indicative of the disease process? -
elevated blood pressure
Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess
volume in the system. Respirations are not typically affected unless there is fluid
accumulation in the lungs. Temperature is not generally affected.
The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value
should the nurse monitor most closely? -
magnesium
Chronic alcohol abuse is a major cause of *symptomatic hypomagnesemia* in the United
States. The serum magnesium concentration should be measured at least every 2 or 3 days in
clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal
at admission but may decrease as a result of metabolic changes, such as the intracellular shift
of magnesium associated with intravenous glucose administration.
The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL
(1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte
imbalance? -
hypocalcemia
The client is experiencing an elevated serum phosphorus concentration. Hyperphosphatemia
is defined as a serum phosphorus that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the
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Balance and Disturbance
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia:
pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these
values indicate? -
respiratory alkalosis
A client with pneumonia may hyperventilate in an effort to increase oxygen intake.
Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis —
indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys'
bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The
below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2
loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance
has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.
Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone
(SIADH) secretion is experiencing complications? -
jugular vein distension
SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention.
Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular
vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight
gain and fluid retention (secondary to oliguria).
Which findings indicate that a client has developed water intoxication secondary to treatment
for diabetes insipidus? -
confusion and seizures
Classic signs of water intoxication include confusion and seizures, both of which are caused
by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN
levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water
intoxication.
Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:
-
muscle weakness
Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue,
and face are findings associated with hyperkalemia, which is transient and results from
transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and
constipation aren't seen in hyperkalemia.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should
the nurse assess first? -
pulse
1|Page
,An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which
the nurse can detect immediately by palpating the pulse. In addition to assessing the client's
pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur
suddenly. The client's blood pressure may change, but only as a result of the arrhythmia.
Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing
respirations and temperature because these aren't affected by the serum potassium level.
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of
solution? -
acidic
Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is
considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
Which electrolyte is a major anion in body fluid? -
chloride
Chloride is a major anion found in extracellular fluid. Potassium, sodium, and calcium are
cations.
Which could be a potential cause of respiratory acidosis? -
hypoventilation
Respiratory acidosis is always due to inadequate excretion of CO2, with inadequate
ventilation, resulting in elevated plasma CO concentration, which causes increased levels of
carbonic acid. In addition to an elevated PaCO2, hypoventilation usually causes a decrease in
PaO2.
A client's potassium level is elevated. The nurse is reviewing the ECG tracing. Identify the
area on the tracing where the nurse would expect to see peaks. -
Peaked narrow T wave
Potassium influences cardiac muscle activity. Alterations in potassium levels change
myocardial irritability and rhythm. Hyperkalemia is very dangerous; cardiac arrest can occur.
Cardiac effects of elevated serum potassium are significant when the level is above 8 mEq/L.
Hyperkalemia causes skeletal muscle weakness and even paralysis, related to a depolarization
block in t muscle. Therefore, ventricular conduction is slowed. The earliest change that can
be seen are peaked, narrow T waves on the ECG.
Which of the following is a factor affecting an increase in urine osmolality? -
syndrome of inappropriate anti diuretic hormone release
Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and
congestive heart failure. Myocardial infarction typically is not a factor that increases urine
osmolality.
A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking
ethacrynic acid (Edecrin) for hypertension. Based on these symptoms, the client will be
evaluated for which electrolyte imbalance? -
hypokalemia
2|Page
, Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias,
leg cramps, muscle weakness, and paresthesias. Many diuretics, such as ethacrynic acid
(Edecrin), also waste potassium.
Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, paresthesias, and
cardiac dysrhythmias.
Signs of hypocalcemia include tingling in the extremities and the area around the mouth and
muscle and abdominal cramps.
Hypercalcemia causes deep bone pain, constipation, anorexia, nausea, vomiting, polyuria,
thirst, pathologic fractures, and mental changes.
The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic
alkalosis. Which nursing actions are required to manage this client? Select all that apply. -
Compare ABG findings with previous results.
Maintain intake and output records.
Document presenting signs and symptoms.
Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate
or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and
increased base bicarbonate. Nursing management includes documenting all presenting signs
and symptoms to provide accurate baseline data, monitoring laboratory values, comparing
ABG findings with previous results (if any), maintaining accurate intake and output records
to monitor fluid status, and implementing prescribed medical therapy.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is
indicative of the disease process? -
elevated blood pressure
Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess
volume in the system. Respirations are not typically affected unless there is fluid
accumulation in the lungs. Temperature is not generally affected.
The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value
should the nurse monitor most closely? -
magnesium
Chronic alcohol abuse is a major cause of *symptomatic hypomagnesemia* in the United
States. The serum magnesium concentration should be measured at least every 2 or 3 days in
clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal
at admission but may decrease as a result of metabolic changes, such as the intracellular shift
of magnesium associated with intravenous glucose administration.
The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL
(1.61 mmol/L). The nurse anticipates that the client will also experience which electrolyte
imbalance? -
hypocalcemia
The client is experiencing an elevated serum phosphorus concentration. Hyperphosphatemia
is defined as a serum phosphorus that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the
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