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Fluid and electrolit
| Question | Answer |
|---|---|
| INTRACELLULAR FLUID (ICF) | Inside cell Most of body fluid here - 40% weight Decreased in elderly |
| EXTRACELLULAR FLUID (ECF) | Intravascular fluid, Interstitial fluid, Transcellular fluid |
| Intravascular fluid | within blood vessels (5%) |
| Interstitial fluid | between cells & blood vessels (15%) |
| Transcellular fluid | cerebrospinal, pericardial , synovial |
| ELECTROLYTES | Substance when dissolved in solution separates into ions & is able to carry an electrical current |
| cation | positive charged electrolyte |
| anion | neg charged electrolyte |
| electrolyte | Substance when dissolved in solution separates into ions & is able to carry an electrical current |
| MILLIEQUIVALENT (mEq) | Unit of measure for an electrolyte |
| Describes electrolyte’s ability to combine & form other compounds | Equivalent weight is amount of one electrolyte that will react with a given amount of hydrogen 1 mEq of any cation will react with 1 mEq of an anion |
| SOLUTE | substance dissolved |
| solvent | solution in which the solute is dissolved |
| selectively permeable membranes | found throughout body cell membranes & capillary walls; allow water & some solutes to pass through them freely |
| METHODS OF FLUID & ELECTROLYTE MOVEMENT | Diffusion Osmosis Active Transport Filtration |
| largest extracellular make-up | sodium & chloride |
| osmolaity of blood | 290-310 |
| tonicity | effective osmolality |
| plasma osmolility | 2x na + glucose/18 + urea/2.8 |
| plasma tonicity | 2 x na + glucose/18 |
| adh | water retaining hormone - vasopressin causing increased retention of h20 |
| aldosterone | sodium retaining hormone |
| ANP | opposite of aldosterone |
| DIFFUSION | Process by which a solute in solution moves Involves a gas or substance ovement of particles in a solution Molecules move from an area of higher concentration to an area of lower concentration Evenly distributes the solute in the solution Passive transp |
| FACILITATED DIFFUSION | Involves carrier system that moves substance across a membrane faster than it would with simple diffusion Substance can only move from area of higher concentration to one of lower concentration |
| OSMOSIS | Movement of the solvent or water across a membrane Involves solution or water |
| OSMOTIC PRESSURE | Pull that draws solvent through the membrane to the more concentrated side (or side with solute ) |
| COLLOID OSMOTIC PRESSURE OR ONCOTIC PRESSURE | Special kind of osmotic pressure Created by substances with a high molecular weight (like albumin) |
| ISOTONIC | ISO - means alike TONICITY - refers to osmotic activity of body fluids; tells the extent that fluid will allow movement of water in & out cell Means that solutions on both sides of selectively permeable membrane have established equilibrium |
| proteins are really needed in patients with severe | burns, surgery, renal patients |
| most abundant protein in the body | albumin |
| Any solution put into body with the same osmolality as blood plasma - 0.9% sodium chloride or 5% glucose | isotonic |
| HYPOTONIC | Solution of lower osmotic pressure Less salt or more water than isotonic Solutions move into cells causing them to enlarge |
| HYPERTONIC | Solution of higher osmotic pressure 3% sodium chloride is example If infused into blood, water moves out of cells & into solution (cells wrinkle or shrivel) Solutions pull fluid from cells |
| OSMOLALITY | Measure of solution’s ability to create osmotic pressure & thus affect movement of water Number of osmotically active particles per kilogram of water Plasma osmolality is 280-300* mOsm/ kg ECF osmolality is determined by sodium |
| Nl Urine sp g range | 1.010 to 1.025 (compared to weight of distilled water with sp g of 1.000) |
| BUN | blood urea nitrogen; made up of urea an end-product of protein metabolism; Nl 10-20 mg/dL; increases with GI bleeding |
| Creatinine | end product of muscle metabolism; better indicator of renal function; nl 0.7-1.5 mg/dL |
| Hematocrit | vol. % of RBCs in whole blood; 44-52% male 39-47% female |
| THIRD SPACING | Large quantities of fluid from the intravascular compartment shift into the interstitial space; is inaccessible to the body May be caused by lowered plasma proteins, increased capillary permeability & lymphatic blockage |
| PLASMA PROTEINS (Primarily Albumin) | Affect serum osmolarity Are main negatively charged intravascular fluid anions Balance the positive charge of sodium in osmolarity |
| plasma proteins part 2 | Create colloid osmotic (oncotic) pressure which pulls in & holds water in the vascular bed as well as pulling water from interstitial space into vascular bed - “water magnet”* |
| THIRST | Conscious desire for water Major factor that determines fluid intake Initiated by the osmoreceptors in hypothalamus that are stimulated by increase in osmotic pressure of body fluids to initiate thirst - Also stimulated by a decrease in the ECF volume |
| ADH (Antidiuretic Hormone) | Made in hypothalamus; water conservation hormone Stored in posterior pituitary gland Acts on renal collecting tubule to regulate reabsorption or elimination of water |
| If blood volume decreases | then ADH is released & water is reabsorbed by kidney. Urine output will be lower but concentration will be increased. |
| ALDOSTERONE | Produced by adrenal cortex Released as part of RAAS mechanism Acts on renal distal convoluted tubule Regulates water reabsorption by increasing sodium uptake from the tubular fluid into the blood but potassium is excreted |
| aldosterone is responsible for | for reabsorption of sodium & water into the vascular compartment |
| RENIN | Released by kidneys in response to decreased blood volume Causes angiotensinogen (plasma protein) to split & produce angiotensin I Lungs convert angiotensin I to angiotensin II |
| Angiotensin II stimulates | adrenal gland to release aldosterone & causes an increase in peripheral vasoconstriction |
| Methods of Monitoring Fluid Balance | BP - one of best tools to assess fluid volume Review technique - ex. Cuff too small Remember auscultatory gap Orthostatic hypotension |
| Water loss | Hemorrhage, burns, diarrhea, vomiting, sweating, diabetes insipidus, diuretics, laxative abuse |
| Excess water gain | Heart failure, renal failure, excessive salt intake, pancreatitis |
| Specific gravity (1.012 to 1.025 normal) | Increased with dehydration |
| Body water | Within cells (intracellular) 40% Outside of cells (extracellular) 20% Interstitial, intravascular, transcellular |
| FLUID VOLUME DEFICIT | Hypovolemia or FVD is result of water & electrolyte loss Compensatory mechanisms include: Increased sympathetic nervous system stimulation increase in heart rate & cardiac contraction Thirst Release of ADH & aldosterone |
| Severe case may result in hypovolemic shock | or prolonged case may cause renal failure |
| anasarca | edema all over the body |
| Water Intoxication (Hyponatremia | Excess fluid moves from EC space to IC space Happens with SIADH, rapid infusion of hypotonic IV sol or tap water as NG irrigant or enemas; can happen with psychogenic polydipsia ( may drink 12-18 L/day ) |
| Water Intoxication findings | Serum Na+ < 125 mEq/L Serum Osmolality < 280 mOsm/kg |
| Crystalloids: | contain Na+ as the main osmotically active particle - useful for volume expansion (mainly interstitial space) - for maintenance infusion - correction of electrolyte abnormality |
| Isotonic crystalloids | Lactated Ringer’s, Hypertonic, Hypotonic |
| lactated ringer's | 0.9% NaCl - only 25% remain intravascularly |
| hypertonic | saline solutions - 3% NaCl |
| Hypotonic solutions | D5W, 0.45% NaCl - less than 10% remain intra- vascularly, inadequate for fluid resuscitation |
| Normal Calcium level | 8.5 to 10.2 mg/dL |
| is the body’s major negative ion | chloride |
| chloride | In the fluid outside the cells, it accompanies sodium in maintaining fluid balances. |
| It is responsible for stomach acidity as it is part of hydrochloric acid. | chloride |
| The principal source of chloride | salt |
| No known diet lacks | chloride |
| ACID-BASE BALANCE | Governed by the regulation of hydrogen ion (H+) concentration in the body |
| ph | negative logarithm of the H+ concentration |
| acids | proton donors & give up H+ |
| bases | H+ acceptors |
| acidic | inc. in concentration of H+ |
| Basic | dec. in concentration of H+ |
| An older adult client is receiving furosemide (Lasix) for treatment of peripheral edema. Which nursing assessment data identify that the client is at risk for falling? | Blood pressure decreases when changing positions. The client may not have sufficient blood flow to the brain, causing sensations of light-headedness and dizziness. This problem increases the risk for falling, especially in older adults. |
| A client has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the client? | A dose of KCl 10 mEq given over 1 hour is appropriate for this client. |
| A client is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond? | The nurse should educate the nursing assistant as to why obtaining the client's weight at the same time each day is important. |
| Which situation can cause a client to experience "insensible water loss"? Select all that apply. | Diarrhea, Dry hot weather, Fever, Increased respiratory rate, Mechanical ventilation |
| Which client is at increased risk for fluid and electrolyte imbalance? | Correct45-year-old man on diuretics, 47-year-old man traveling to South America in summer, 76-year-old bedridden woman |
| A nurse instructs an older adult client to increase intake of dietary potassium when the client is prescribed which classification of drugs? | High-ceiling (loop) diuretics are potassium-depleting drugs. The client should increase intake of dietary potassium to compensate for this depletion. |
| A nurse is instructing a client who is being discharged with a diagnosis of congestive heart failure (CHF). Which client statement indicates a correct understanding of CHF? | Rapid weight gain is the best indicator of fluid retention and overload. Each pound of weight gained (after the first half-pound) equates to 500 mL of retained water. The client should be weighed at the same time every day |
| Which client is at greatest risk for hypernatremia? | 54-year old who is sweating profusely, Excessive sweating is a common cause of hypernatremia. |
| As adults age, which common physiologic change is likely to alter their hydration status? | Decreased muscle mass causes decreased total body water, thus altering hydration status in the older adult. |
| A nurse is reviewing serum electrolytes and blood chemistry for a newly admitted client. Which result causes the greatest concern? | A potassium value of 5.9 mEq/L is high, and the client should be assessed further. |
| A client with hyperkalemia is being treated with drugs to improve the condition. Which potassium level indicates that therapy is effective? | A potassium level of 4.6 mEq/L is a normal level, indicating that therapy was effective. Normal levels are 3.5 to 5.0 mEq/L. |
| A client is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first? | Respirations, respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations. Thus, respiratory status should be assessed first in any client who might have hypokalemia |
| A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? | : Elevating the head of the bed will ease breathing for the client. |
| A nurse is assessing a client with hyponatremia. Which finding requires immediate action? | Muscle weakness in clients with hyponatremia requires immediate action. If muscle weakness is present, immediately check respiratory effectiveness because ventilation is dependent on adequate strength of the respiratory muscles. |
| A nurse is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. What does the nurse tell them? | Offer fluids - Because of the decreased thirst mechanism, older adults should be offered oral fluids every 2 hours. The likelihood of their accepting the fluid increases if the fluid is one they prefer. |
| A nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate (MgSO4). Which assessment parameter is critical? | Hourly deep tendon reflexes (DTRs) - The client who is receiving IV MgSO4 should be assessed for signs of toxicity every hour by assessment of DTRs. |
| The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is assigned to the LPN/LVN? | 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L - Although the client has poor skin turgor, the serum osmolarity indicates that fluid balance is normal; this client is the most stable of the four clients described |
| The client is a 69-year-old woman with uncontrolled diabetes, polyuria, and a blood pressure of 86/46. Which staff member is assigned to care for her? | The clinical manifestations suggest that the client is experiencing hypovolemia and possible hypovolemic shock. The RN who floated from the intensive care unit will have extensive experience caring for clients with hypovolemia. |
| A nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? | Offering fluids to drink every hour - Encouraging a client to take oral fluids is within the scope of practice for UAP. |
| An RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? | Positioning the client in a semi-Fowler's position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on client comfort |
| Which newly written physician prescription does the nurse administer first? | Oral potassium chloride (KCl) to a client whose serum potassium is 3 mEq/L - Because minor changes in serum potassium level can cause life-threatening dysrhythmias, the first priority should be to administer potassium to the client with hypokalemia. |
| A physician writes orders for a client who is admitted with a serum potassium (K) level of 6.9 mEq/L. What does the nurse implement first? | Because hyperkalemia can lead to life-threatening bradycardia, the initial action should be to place the client on a cardiac monitor. |
| he nurse manager of the medical-surgical unit assigns which client to the LPN/LVN? | 64-year-old admitted yesterday with heart failure who still has dependent pedal edema - Because the client with heart failure is the most stable of the four clients, this client is most appropriate to assign to the LPN/LVN. |
| An RN is caring for a client admitted with dehydration who requires a blood transfusion. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)? | Obtaining baseline vital signs before blood administration - UAP education includes assessment of vital signs. |
| An RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to unlicensed assistive personnel (UAP)? | Providing oral care every 1 to 2 hours Correct: Frequent oral care is an important intervention for a client with fluid volume deficit and is appropriate to delegate to UAP. |
| After receiving change-of-shift report, which client does the RN assess first? | 46-year-old receiving IV diuretics whose blood pressure is 95/52 mm Hg has history of receiving IV diuretics and having low blood pressure indicates that the client may be experiencing hypoperfusion caused by hypovolemia, and that immediate assessment. |
| An RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? | The client's change in level of consciousness suggests poor cerebral blood flow or shrinkage or swelling of brain cells caused by fluid shifts within the brain cells. These changes, need for immediate intervention to prevent further damage to cerebral fun |
| The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? | Calcium level of 9.5 mg/dL Correct: Because this client's calcium level is within normal limits, it is appropriate to assign the client to an LPN/LVN. |
| A 90-year-old client with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the client for admission to which inpatient unit? | Because hypermagnesemia causes changes in the electrocardiogram that may result in cardiac arrest, the client should be admitted to the Telemetry/Cardiac Step-Down unit. |
| A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? | Measurement of the client's urine output Correct: A home health aide may measure the client's intake and output, which then would be reported to the RN. |
| A nurse is planning care for a client with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)? | Transferring the client from the bed to a stretcher using a lift sheet Correct: Transferring clients is a nursing skill that is included in UAP education and scope of practice. |
| A client is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first? | Obtaining a pulse oximetry reading, Because hypokalemia may cause respiratory insufficiency and respiratory arrest, the client's respiratory status should be assessed first. |
| A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failu | If potassium levels are high, a combination of 20 units of regular insulin in 100 mL of 20% dextrose may be prescribed to promote movement of potassium from the blood into the intracellular fluid (ICF). |
| : A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart fai | Restoring fluid balance by controlling the causes of dehydration Correct: Drug therapy for dehydration is directed at restoring fluid balance and controlling the causes of dehydration. |
| A 70-year-old female is admitted to the hospital with heart failure, shortness-of-breath (SOB), and 3+ pitting edema in her lower extremities. Her current medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) in | Increased urine output Correct: When giving Lasix, the nurse monitors the client for response to drug therapy, especially weight loss and increased urine output. |
| Which of these clients would be appropriate to assign to the new nurse working on the unit? | A client with emphysema and cellulitis with a PaCO2 level of 58 mm Hg Correct: This finding, although abnormal, is anticipated for a client with chronic obstructive pulmonary disease (COPD) and is stable for a new graduate. |
| A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is indicated? | the incentive spirometer - Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway and expanding the lungs through breath |
| The nurse is caring for a client with hypoxemia and metabolic acidosis. Which of these tasks can be delegated to the nursing assistant who is helping with the client's care? | Apply the pulse oximeter for continuous readings. Correct: Placing a peripheral pulse oximeter is a standardized nursing skill that is within the scope of practice for unlicensed personnel. |
| Which nursing intervention takes priority for a client admitted with severe metabolic acidosis? | Initiate cardiac monitoring. Correct: The nurse follows the ABCs and initiates cardiac monitoring to observe for signs of hyperkalemia or cardiac arrest. |
| The nurse is caring for a critically ill client with septic shock. The serum lactate level is 6.2. For which of the following acid-base disturbances should the nurse assess? | Metabolic acidosis Correct: Increased lactate levels are associated with hypoxia and metabolic acidosis secondary to anaerobic metabolism. |
| The nurse is caring for a client who has taken a large quantity of furosemide (Lasix) to promote weight loss. The nurse anticipates the finding of which acid-base imbalance? | HCO of 34 mEq/L Correct: Diuretics (non-potassium sparing) cause metabolic alkalosis. |
| The nurse is caring for a client with an oxygen saturation of 88% and accessory muscle use. The nurse provides oxygen and anticipates which of these physician orders? | Intubation and mechanical ventilation Correct: Support with mechanical ventilation may be needed for clients who cannot keep their oxygen saturation at 90% or who have respiratory muscle fatigue. |
| The nurse is caring for a group of clients with acidosis. The nurse recognizes that Kussmaul respirations are consistent with which situation? | Aspirin overdose Correct: If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises; this is known as Kussmaul respirations. Metabolic acidosis is caused by alcoholic beverages, methyl alcohol, and acet |
| Which action should the nurse take first for the client who is admitted to the emergency department (ED) with a panic attack and whose blood gases indicate respiratory alkalosis? | Encourage the client to take slow breaths. Correct: Because respiratory alkalosis is caused by hyperventilation, the nurse's first action should be to assist the client in slowing the respiratory rate. |
| To decrease the risk of acid-base imbalance, what goal must the client with diabetes mellitus strive for? | Maintaining blood glucose level within normal limits Correct: Maintaining blood glucose levels within normal limits is the best way to decrease the risk of acid-base imbalance. |
| Which client is most likely to exhibit the following ABG results: pH, 7.30; PaCO2, 49; HCO , 26; PO2, 76? | Client taking hydromorphone (Dilaudid) Correct: Hydromorphone (Dilaudid), a narcotic analgesic, can cause respiratory depression, hypoventilation, and respiratory acidosis, as this blood gas reading demonstrates |
| When caring for a group of clients at risk for respiratory acidosis, the nurse identifies which person as at highest risk? | Cigarette smoking worsens gas exchange, leading to disorders that contribute to hypoventilation and respiratory acidosis. |
Created by:
hajet