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ATI-MedSurge-Fluid
ATI-MedSurge-FLUIDS-Electrolyte, Acid-Base
| Question | Answer |
|---|---|
| Potassium of 3.0 mEq/L - expected assessment | Orthostatic hypotention |
| Dehydrated pt. begins to appear confused / lethargic - priority nursing action | report the findings to primary care provider |
| Hyponatremia - sodium | sodium serum -< 135 mEq/L |
| Hypernatremia - sodium | sodium serum -> 145 mEq/L |
| Hyponatremia - osmolarity | serum osmolarity -< 270 mOsm/L |
| Hypernatremia - osmolarity | serum osmolarity -> 300 mOsm/L |
| serum sodium 155 mEq/L - good PO | isotonic - 1000 mL 0.9% saline hypotonic - 1000 mL 5% dextrose w/H2O hypotonic - 1000 mL 5% dextrose w/045% saline |
| serum sodium 155 mEq/L - bad PO | hypertonic - 1000 mL 3% saline |
| 2+ pitting ankle edema - serum assessments | increased serum: hematocrit, osmolarity (>300 mOsm/L), urine specific gravity, sodium |
| Prolonged PR interval and widened QRS complex - due to... | Hyperkalemia |
| Magnesium - Rich Foods | Spinach Halibut Tofu Broccoli Brown Rice Scallop Pumpkin seeds Beet greens Buckwheat |
| Excessive fluid loss - Interventions | - administer prescribed IV fluids - increase fluids - pt. to stand slowly - weigh pt. each morning |
| ABGs - Metabolic alkalosis | pH > 7.45 |
| ABGs - Metabolic acidosis | pH < 7.45 |
| Dehydrated pt. - receiving IV fluids - s/s Fluid Overload | bounding peripheral pulses |
| Venous insufficiency lower extremities - pt. teaching | put feet up when sitting |
| Elastic stockings | put on upon awakening and before getting out of bed in the morning, seam on the OUTSIDE |
| Pt. teaching for Post-OP client at risk for developing respiratory acidosis | use incentive spirometer to promote adequate gas exchange |
| hypercalcemia - nursing priority assessment | assess cardiac rhythm due to risk of cardiac dysrhythmias |
| Calcium - High Foods | green beans, broccoli |
| Hypercalcemia - nursing plan of action | implement seizure precautions |
| Calcium - administration | PO or IV, not IM |
| Hypokalemia due to Furosemide (Lasix) - prepare to administer | Potassium Sparing Diuretic |
| Potassium - administration | via IV solution at 10 mEq/L ***NEVER IV BOLUS*** |
| Hyperkalemia - IV intervention | administer high dextrose (D50W) & regular insulin IV to decrease serum potassium level |
| Hypomagnesemia - expected finding | hyperactive deep tendon reflexes decreased bowel sounds shallow respiration increased BP |
| Hypomagnesemia - serum level | < 1.3 mg/dL |
| Hypokalemia - IV intervention | normal saline w/ 40 mEq/L K+ at 100 mL/hr |
| Lactated Ringer's solution - for vomiting | will not provide adequate K+ replacment |
| PaCO2 in respiratory alkalosis is... | decreased |
| Isotonic dehydration causes a loss of? | water only |
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